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fHacmillairs  fHanuals  of 
fHrliicinc  anti  Surgcru 


A    MANUAL    OF    SURGERY 


y^/^^ 


^5-^2_:=— o 


A 


Manual  of  Surgery 


BY 


CHARLES    STONHAM,    F.R.C.S.Eng. 

SENIOR    SURGEON    TO    THE    WESTMINSTER    HOSPITAL;    LECTURER   ON    SURGERY   AND   ON    CLINICAL 

SURGERY,  AND    TEACHER    OF    OPERATIVE    SURGERY,    WESTMINSTER    HOSPITAL;    SURGEON 

TO    THE    POPLAR    HOSPITAL    FOR    ACCIDENTS  ;    EXAMINER    IN    SURGERY,   SOCIETY 

OF    APOTHECARIES,    LONDON;    LATE    MEMBER    OF    THE    P.OARD    OF 

EXAMINERS    IN    ANATOMY    UNDER    THE   CONJOINT 

SCHEME    FOR    ENGLAND,  ETC.  ETC. 


IN     THREE     VOLUMES 


VOL.    L— GENERAL  SURGERY 


jSTtto  gorft 
THE    MACMILLAN   COMPANY 

LONDON  :  MACMILLAN  &  CO.,  Ltd. 
1900 

All  rights  reserved 


Copyright,  1900, 
By   the   MACMILLAX   COMPANY. 


XI^3l 


Norbjooli  ISrtss : 

Berwick  &  Smith,  Norwood,  Mass.,  U.S.A. 


PREFACE 

The  object  of  this  work  is  to  give  a  succinct  account  of 
modern  surgical  pathology,  diagnosis,  and  treatment,  and  it 
is  intended  as  a  manual  for  practitioners  and  students. 

Much  of  merely  historical  interest  has  been  purposely 
omitted,  partly  on  account  of  want  of  space,  and  partly 
because  a  repetition  of  what  is  already  in  print,  but  now  out 
of  date,  is  undesirable. 

In  a  work  such  as  this  it  must  necessarily  happen  that 
certain  rare  conditions  can  only  be  treated  of  briefly;  but  so 
far  as  possible,  I  have  embodied  the  results  of  sixteen  years' 
experience  as  a  hospital  surgeon  and  teacher. 

My  best  thanks  are  due  to  those  gentlemen  who  have  so 
kindly  rendered  me  valuable  assistance  ;  to  Mr.  Donald 
Gunn  who  has  contributed  the  chapter  in  vol.  ii.  on  Injuries 
of  the  Eye  ;  to  my  colleagues,  Mr.  Tubby,  Mr.  de  Santi, 
and  especially  Mr.  Paton,  who  has  read  the  entire  MSS., 
and  given  me  many  valuable  suggestions  ;  he  has  also  given 
me  great  assistance  in  the  selection  of  illustrations.  The 
original  illustrations  are  from  drawings  made  for  me  b}' 
Miss  Booth,  Mr.  C.  H.  Freeman,  and  Mr.  G.  C.  Coltart,  and 
I  thank  them  for  the  care  and  skill  they  have  exhibited  in 
their  work. 


vi  MANUAL   OF   SURGERY 

I  also  desire  to  offer  my  cordial  thanks  to  those  authors 
and  publishers  who  have  permitted  me  to  make  use  of  their 
illustrations,  the  source  of  which  I  have  acknowledged  in 
the  text. 

Finally,  I  must  thank  Messrs.  Macmillan  for  their 
liberality  in  the  matter  of  illustrations,  and  the  courtesy  with 
which  they  have  carried  out  all  my  suggestions. 

C.   S. 

4  Harley  Street,  W., 
1S99. 


CONTEXTS 


CHAPTER  I 


PAGE 


The  Degenerations,  Atrophy,  and  Hypertrophy  .         i 

The  degenerations,  i  ;  varieties,  3  ;  fatty,  3  ;  albuminoid,  4  ;  colloid 
and  mucoid,  6  ;  calcareous  infiltration,  6  ;  atrophy,  7  ;  hyper- 
trophy, 8. 

CHAPTER  n 

Local  Circulatory  Disturbances — Inflammation  9 

Ischemia,  9  ;  anaemia,  active  arterial  hyperaemia,  venous  congestion, 
10  ;  inflammation,  11-37  ;  acute,  15-33  ;  chronic,  33-36  ;  catarrhal, 
36. 

CHAPTER  HI 
Suppuration  and  Abscess  .  .  .  •       3^ 

Acute  abscess,  38  ;  pyogenic  organisms,  40  ;  chronic  abscess,  46  ; 
sinus,  51  ;  fistula,  54. 

CHAPTER  IV 
Ulceration  and  Ulcers    .  .  .  .  •       56 

Simple  or  non-specific  ulceration,  56  ;  the  healing  sore,  64  ;  indolent 
or  callous  ulcer,  weak  ulcer,  65  ;  irritable,  varicose,  and  hemor- 
rhagic ulcers,  66  ;  inflamed  and  sloughing  ulcers,  67  ;  constitutional 
ulcers,  syphilitic,  tubercular,  scorbutic,  diabetic,  67  ;  gouty,  68  ; 
ulcers  of  nervous  origin,  68  ;  infective  ulcers,  68  ;  ulcers  due  to 
tumours,  68. 


viii  MANUAL   OF  SURGERY 


CHAPTER  V 

PAGE 

Gangrene  .  .  .  .  •  *       T^ 

General  account,  70 ;  gangrene  from  pressure,  77  ;  from  arterial 
disease,  ■  senile  gangrene,  79  ;  from  arterial  spasm,  Raynaud's 
disease,  82  ;  from  ergotism,  84  ;  diabetic  gangrene,  84  ;  gangrene 
due  to  micro-organisms,  86. 


CHAPTER  VI 
Bacteriology         •  •  .  .  .  •       ^7 

The  bacteria,  structure,  and  characters,  88  ;  classification,  89  ;  life- 
history,   90  ;  products,   92  ;   reproduction,   mutability   of  species, 

93  ;  bacteria  in  relation  to  the  living  body,  94  ;  mode  of  action, 

94  ;  proneness  to  infection,  95  ;  immunity,  96  ;  phagocytosis,  97  ; 
chemical  theory  of  immunity,  100. 

CHAPTER  Vn 
Surgical  Septic  and  Infective  Diseases  .  .102 

Definition  and  classification,  102  ;  simple  septic  diseases,  105  ;  acute 
septic  intoxication,  106;  chronic,  108;  local  infective  diseases, 
109;  furuncle,  carbuncle,  109  ;  facial  carbuncle,  112  ;  malignant 
pustule,  112;  cancrum  oris,  115;  hospital  gangrene,  116; 
sloughing  phagedsena,  118;  wound-diphtheria,  119;  emphyse- 
matous gangrene,  120;  cutaneous  erysipelas,  122;  cellule- 
cutaneous  erysipelas,  127;  cellulitis,  129;  rabies,  131;  tetanus, 
136;  actinomycosis,  139;  mycetoma,  141. 


CHAPTER  VIII 

Surgical  Infective  Diseases  {continued)    .  .  .143 

Tubercle,  143;  causes,  144;  modes  of  infection,  145;  morbid 
anatomy,  146;  diagnosis,  149;  prognosis,  150;  principles  of 
treatment,  150;  tuberculin,  151  ;  subcutaneous  tubercular  abscess, 
152;  tubercular  ulcers,  152;  anatomical  wart,  153;  lupus,  153; 
Lupus  erythematosus,  154. 


CONTENTS  ix 


CHAPTER  IX 

PACK 

Surgical  Infective  Diseases  {contimied)     .  .  .156 

GonorrhuM,  156;  in  the  male,  157;  in  the  female,  162;  complica- 
tions and  scciuckv,  163. 

Syphilis,  16S  ;  acquired,  169  ;  primary',  171  ;  secondary,  172  ;  latent, 
174;  tertiary,  174;  syphilitic  affections  of  the  skin,  176; 
mucous  membranes,  hair,  185;  nails,  lymphatic  glands,  186; 
muscles,  bursne,  joints,  187  ;  bones,  blood-vessels,  188  ;  nervous 
system,  eyes,  189  ;  viscera,  190  ;  prognosis  and  treatment,  190. 

Congenital  syphilis,  200  ;  transmission,  200  ;  early  stage,  20I  j  late 
stage,  205  ;  prognosis,  treatment,  207. 

Soft  chancre  or  chancroid,  208. 


CHAPTER  X 
Surgical  Infective  D\?>y.asy.s  (contimied)  .  .  .213 

General  infective  diseases,  213  ;  acute  septic  infection,  215  ;  chronic, 
216  ;  acute  pycemia,  216  ;  chronic,  219  ;  equinia  or  glanders,  219. 


CHAPTER  XI 
Tumours  and  Cysts  .  .  .  .  .222 

Tumours,  general  account,  222  ;  classification,  230  ;  sarcomata,  232  ; 
varieties,  233  ;  lipomata,  237  ;  fibromata,  239  ;  myxomata,  240  ; 
chondromata,  241  ;  osteomata,  242  ;  odontomata,  244  ;  myomata, 
neuromata,  angiomata,  245  ;  lymphangiomata,  psammomata, 
papillomata,  246  ;  adenomata,  248  ;  carcinomata,  250  ;  glandular 
carcinoma,  253  ;  epitheliomata,  255  ;  rodent  cancer,  257. 

Congenital  tumours,  teratomata,  dermoids,  258. 

Cysts,  general  account,  260  ;  retention  cysts,  sebaceous  cysts,  262  ; 
exudation  cysts,  263  ;  extravasation,  implantation,  and  parasitic 
cysts,  264. 

CHAPTER  XII 
Deformities  ,  .  .  .  .  .265 

Spina  bifida,  265  ;  spina  bifida  occulta,  268  ;  spinal  curvature,  269  ; 
lordosis,  kyphosis,  270  ;  scoliosis,  272  ;  crania  bifida,  275  ;  torti- 
collis, 276  ;  hare-lip,  278  ;  cleft  palate,  282. 


MANUAL   OF   SURGERY 

Talipes,  285  ;  talipes  calcaneus,  287  ;  talipes  equinus,  288  ;  talipes 
valgus  and  varus,  289  ;  congenital  talipes  equino-varus,  290  ; 
tarsotomy  and  tarsectomy,  292  ;  acquired  talipes  equino-varus, 
293  ;  talipes  cavus,  294  ;  talipes  calcaneo-valgus,  295  ;  pes 
planus,  295  ;  tenotomy,  297  ;  fasciotomy  and  syndesmotomy, 
299 ;  genu  valgum,  299  ;  osteotomy,  302  ;  bow-legs,  genu 
varum,  and  genu  recurvatum,  303  ;  hallux  valgus,  304  ;  hallux 
rigidus,  305  ;  ingrowing  toe-nail,  305  ;  hammer-toe,  306  ;  syn- 
dactylism, polydactylism,  and  Dupuytren's  contraction,  307  ;  con- 
tracted fingers,  club-hand,  309. 

Malformations  of  the  genito-urinary  tract,  rectum,  and  anus,  309  ; 
normal  development,  309;  imperforate  urethra,  310;  epispadias, 
hypospadias,  311  ;  patent  urachus,  313;  allantoic  cysts,  313; 
ectopia  vesicae,  313;  cleft  scrotum,  adherent  labia,  314;  mal- 
formations of  the  rectum  and  anus,  314  ;  congenital  sacral 
tumour,  316. 


INDEX      .  .  .  .  ,  .  .317 


LIST  OF  ILLUSTRATIOiNS 


The  names  in  italics  are  those  of  the  draughtsmen  of  original  illustrations. 


FIG. 

1.  Fatty  infiltration  and  degeneration  of  liver  cells 

2.  Amyloid  kidney  with  fatty  degeneration 

3.  \'eins  and  capillaries  from  inflamed  mesentery 

4.  Inflamed  omentum         .... 

5.  Anthrax  of  pigeon — phagocytosis 

6.  Formation  of  scar-tissue  in  chronic  hepatitis 

7.  Colony  of  streptococcus  erysipelatis 

8.  Colonies  of  micrococci  in  hepatic  capillaries 

9.  Staphylococcus  pyogenes  aureus  and  pus  cells    . 

10.  Streptococcus  pyogenes 

11.  Abscess  formation  .  .  .  . 

12.  Diagram  of  the  common  forms  of  fistula;  in  ano 

13.  Varicose  veins  and  ulcer 

14.  Osteoplastic    periostitis   resulting    from    chronic 

ulcer  .  .  .  .  . 

15.  Chronic  ulcer  of  the  leg 

16.  The  same  ulcer  thirteen  days  after  skin  grafting 

17.  Gangrene    from    poisoning    by    the    sting    of    a 

weaver  fish  .... 

18.  Dry  gangrene  of  the  foot  and  leg 

19.  Gangrene  from  injury    . 

20.  Symmetrical  gangrene — Raynaud's  disease 

21.  Typhoid  bacilli  with  flagella 

22.  Spirilla  and  red  blood  cells 

23.  Anthrax  bacilli  and  spores 

24.  Anthrax  of  pigeon — phagocytosis 

25.  Anthrax  bacilli  and  spores 

26.  Malignant  pustule 

27.  Bacilli  of  malignant  oedema 

28.  Section    of    skin    at    the    spreading    margin    in 

erysipelas     .... 

29.  Tetanus  bacilli  and  spores 


AUTHOR 

Ziegler 
Ziegler 
Billroth    . 
Ziegler 
Melchnikoff 
Ziegler 
Ziegler 
Ziegler 
G.  Col  I  art 
G.  Col  tart 
Watson  Cheyne 
Foil  in 
Tiilmans . 

C.  H.  Freeman  . 
E.J.  Bitdd-Budd 
E.  J.  Btidd-Bitdd 

C.  H.  Freetnan 

P'ollin 

C.  H.  Freeman 

C.  H.  Freeman 

G.  Coltart 

G.  Coltart 

G.  Coltart 

MetchnikofF 

G.  Coltart 

Follin 

G.  Coltart 

Watson  Cheyne 
G,  Coltart 


3 

5 

16 

17 
19 

39 
40 
40 

41 
42 

54 

57 

59 

62 
62 

71 
74 
75 
83 
89 
90 

93 

98 

113 

113 
120 

123 
1^,6 


Xll 


MANUAL  OF   SURGERY 


30.  Actinomycosis  hominis  . 

31.  Tubercle  bacilli  in  sputum 

32.  Miliary  tuberculosis  of  the  liver 

33.  Tubercular  nodule  from  synovial  membrane 

34.  Gonococci  and  pus  cells 

35.  Syphilitic  ulcers  and  condylomata 

36.  Rupia  syphilitica 

37.  Pemphigus  and  ulceration  in  congenital  syphilis 

38.  Syphilitic  Assuring  of  the  tongue 

39.  Syphilitic  dactylitis  and  onychia 

40.  Syphilitic  caries  and  necrosis  of  the  skull 

41.  Parrot's  bossing  in  congenital  syphilis 

42.  Malformed  teeth  in  congenital  syphilis 

43.  Colonies  of  micrococci  in  hepatic  capillaries 

44.  Bacillus  mallei  . 

45.  Acute  glanders  . 

46.  Cartilage  island  in  rickety  femur 

47.  Ossifying  periosteal  sarcoma  of  the  femur 

48.  Alveolar  sarcoma  of  a  lymphatic  gland 

49.  Cells  from  a  spindle-celled  sarcoma 

50.  Cells  from  a  myeloid  sarcoma    . 

51.  Lipoma  in  the  palm  of  the  hand 

52.  Cells  from  a  myxoma     . 

53.  Chondromata  of  a  finger 

54.  Subungual  exostosis 

55.  Ivory  osteoma  of  the  frontal  bone 

56.  Cancellous  osteoma  of  the  tibia  . 

57.  Cutaneous  horn  from  the  hand  . 

58.  Villous  tumour  of  the  bladder     . 

59.  Tubular  adenoma  of  the  breast  . 

60.  Scirrhous  carcinoma  of  the  breast 

61.  Cancerous  embolus  in  a  hepatic  capillary 

62.  Ulcerating  scirrhus  of  the  breast 

63.  Section  of  an  epithelioma  of  the  skin 

64.  Dermoid  of  the  scalp  connected  with  the  dura 

mater 

65.  Sebaceous  tumours  in  scalp  and  horn 

66.  Myelo-meningocele  in  the  lumbar  region 

67.  Kyphosis 

68.  Scoliosis 

69.  Scoliosis 

70.  Altered  shape  of  the  chest  in  scoliosis 
70A.  Meningocele  at  the  root  of  the  nose 

71.  Congenital  torticollis 

72.  Single  hare-lip  on  the  right  side 

73.  Single  hare-lip  on  the  left  side   . 

74.  Double  hare-lip  and  cleft  palate 

75.  Rose's  operation  for  single  hare-lip,  first  stage 

76.  Rose's  operation  for  single  hare-lip,  completed 

77.  Mirault's  operation  for  single  hare-lip     . 

78.  Mirault's  operation  for  single  hare-lip     . 


Ziegler 

G.  Coltart 

Ziegler 

Ziegler 

G.  Coltart 

Jullien 

Tu]lien 

Follin       . 

Follin 

Follin 

Follin 

C.  H.  Freemayi 

Hutchinson 

Ziegler 

G.  Coltart 

Tillmans  . 

Bland  Sutton 

Bland  Sutton 

Ziegler 

Ziegler 

Ziegler 

Bland  Sutton 

Ziegler 

Fergusson 

Bland  Sutton 

C.  H.  Freeman 

Ziegler 

Ziegler 

Bland  Sutton 

Ziegler 

Ziegler 

Ziegler 

Follin       . 

Ziegler 

Bland  Sutton 

Bryant 

C.  H.  Freemaft 

Follin 

Follin 

Tillmans  . 

Tubby 

Bryant 

Tubby 

Follin 

Follin 

C.  H.  Freeman 

G.  Coltart 

G.  Coltart 

G.  Coltart 

G,  Coltart 


140 

145 
147 
148 
156 
180 
182 

183 
185 
186 
188 
204 
206 
217 
219 
220 
223 
227 
234 
235 
236 
238 
241 
242 
242 
243 
243 
247 
248 
249 
250 
251 
254 
255 

259 
263 
267 
271 
272 
273 
274 
275 
277 

279 
279 
279 
280 
280 
2  So 
2S0 


LIST   OF   ILLUSTRATIONS 


Xlll 


FIG. 

79.  Mirault's  operation  for  sintjlc  hare-lip,  completed 

80.  Dtniblc  hare-lip,  profile  view 

81.  rrcniaxillary  bone,  anterior  view 

82.  rromaxilliiry  bone,  posterior  view 

83.  Rose's  operation  for  double  hare-lip,  first  stage 

84.  Rose's  operation  for  double  hare-lip,  completed 
85  Cleft  palate         .... 

86.  Cleft  palate,  united  by  operation 

87.  Talipes  calcaneus 

88.  Tubliy's  modification  of  Thomas's  wrench 

89.  Walking  aj^paratus  for  talipes  calcaneus 

90.  Talipes  eipiinus 

91.  Talipes  varus     . 

92.  Congenital  talipes  equino-varus 

93.  Tin  shoe  with  quadrant  movement 

94.  Acquired  talipes  equino-varus     . 

95.  Talipes  arcuatus  , 

96.  Talijics  plantaris 

97.  Pes  planus 

98.  Whjtman's  valgus  sole-pad  applied 

99.  Genu  valgum     . 

100.  Genu  valgum,  after  operation     . 

10 1.  Genu  varum 

102.  Hallux  valgus    . 

103.  Ingrowing  toe-nail 

104.  Onychia  "maligna" 

105.  Hammer-toe 

106.  Dupuytren's  contraction,  dissection 

107.  Dupuytren's  contraction 

108.  Peno-scrotal  hypospadias  , 

109.  Peno-scrotal  hypospadias 
no.  Imperforate  rectum 

111.  Imperforate  anus 

1 1 2.  Absent  rectum  . 

113.  Atresia  ani  vesicalis 

114.  Atresia  ani  urethralis 

115.  Atresia  ani  vaginalis 


ADTJIOR 

G.  Coltart 
I'ergusson 


G. 
G. 
G. 

G. 
G. 
G. 


Col/at 
Coltar 
Co  I  hi} 
Collar 
CoUai 
Collaf 


P'ollin 

Messrs.  Down  Bros. 

Tubby 

Follin 

Follia 

Tubby 

Tubby 

Tubby 

Tubby 

Tubby 

Tul)by 

Tulsby 

Follin 

Follin 

Tubby 

Follin 

Follin 

Fergusson 

Tubby 

Tubby,  after  Druitt 

Fergusson 

Follin 

Follin 

C.  Broivn 

C.  Browit 

C.  Brown 

C.  Bro7v>i 

C.  Brown 

C.  Brown 


2  So 
281 
28 1 
2S1 
282 
282 
2S3 

283 
287 
288 
288 
288 
290 
290 
2-91 
293 
294 
294 
295 
296 
301 
302 
303 
304 
305 
305 
306 
308 
308 
312 
312 

3-'5 
315 
315 
315 
315 
315 


CHAPTER     I 

The  Degenerations,  Atrophy,  and  Hypertrophy 

The  Degenerations 

A  tissue  is  said  to  be  degenerated  when,  owing  to  some  change 
in  its  structure  and  composition,  its  physiological  importance  is 
deteriorated,  and  hence  its  usefulness  in  the  economy  is  proportion- 
ately diminished.  A  degeneration  properly  so-called  is  a  true 
metamorphosis,  the  normal  tissue  undergoing  some  chemical  change, 
whereby  it  is  converted  into  something  else,  e.g.  muscle  into  fat.  A 
tissue  may,  however,  be  unfiltrated  or  replaced  by  some  new  chemical 
substance,  and  itself  merely  undergo  atrophy  or  some  genuine 
degenerative  change;  this  process  is  known  as  an  infiltration. 
Metamorphosis  and  infiltration  are  usually  associated  conditions, 
and  in  either  case  the  ultimate  physiological  degradation  of  the 
affected  tissue  is  much  the  same ;  but  in  infiltration  the  repair  may 
be  complete,  provided  that  the  infiltrating  material  becomes 
absorbed.  The  degenerations  may  not  only  affect  tissues  normal 
to  the  organism,  but  also  new  growths  and  inflammatory  effusion. 

Causes. — Some  of  the  degenerations  occur  in  various  tissues  as 
perfecdy  normal  processes  in  their  Hfe-history ;  thus  fatty  degenera- 
tion occurs  in  the  epithelium  cells  of  the  breast  during  lactation. 
The  actual  change  therefore  cannot  be  regarded  as  any  new 
process,  and  can  only  be  considered  as  pathological  when  it 
occurs  at  a  time,  or  in  a  tissue  when,  on  physiological  grounds, 
we  should  not  expect  it.  Physiological  degeneration  is  then  a 
normal  process  in  the  life-history  of  the  cell.  The  ultimate  fate  of 
all  living  cells  is  death  ;  the  individual  tissues,  hke  the  body  of 
which  they  form  a  part,  have  a  definite  hfe-history;   they  reach  a 

VOL.    I  B 


2  MANUAL   OF   SURGERY  chap. 

certain  state  of  physiological  perfection,  enjoy  this  for  a  time,  and 
then  gradually  deteriorate  and  finally  die,  to  be  replaced  by  new 
cells.  No  cell  in  the  body  is  stable  ;  the  enjoyment  of  vital  activity 
entails  the  death  penalty,  but  between  full  physiological  vigour  and 
death  there  is  the  stage  of  degeneration  or  gradual  atrophy,  and 
hence  the  causes  of  these  conditions,  when  considered  from  a 
pathological  standpoint,  must  be  sought  in  some  state  inducing 
deficiency  of  normal  nutrition. 

Nutrition. — The  proper  maintenance  of  nutrition  is  dependent 
upon  a  variety  of  conditions  acting  harmoniously  for  the  common 
benefit. 

(i)   There  must  be  an  adequate  supply  of  blood. 

(2)  The  blood  must  be  of  good  quality.     These  two  conditions 

imply  the  due  supply  of  oxygen  and  the  removal  of  waste 
material. 

(3)  There  must  be   that  inherent  power  in  the   tissues  them- 

selves which  enables  them  to  convert  to  their  own  uses 
the  nutritive  material  supplied  by  the  blood.  This  quality 
depends  in  great  measure  upon  — 

(4)  Connection  with  a  healthy  nervous  mechanism. 

The  precise  influence  of  the  ner\'ous  system  in  general 
nutrition  is  at  present  unknown,  but  numerous  instances 
of  its  primary  importance  may  be  easily  given.  Thus  a 
lesion  of  a  nerve  leads  to  nutritive  defects  in  the  parts 
which  it  suppHes,  exhibited  clinically  by  skin  affections, 
ulcerations,  and  sometimes  by  sloughing,  e.g.  perforating 
ulcer  of  the  foot,  acute  bed-sores,  and  cystitis  from  spinal 
injury.  No  doubt  the  action  of  the  nervous  system  is 
complex,  since  it  regulates  the  circulation,  sensation,  and 
the  functional  activity  of  the  part. 

(5)  The    due    exercise  of  function  serves  to    maintain   proper 

nutrition,  since  it  is  associated  with  increased  circulation, 
and   hence   a   constant   supply  of  nutritive  material   and 
removal  of  waste  products. 
The  foregoing  being  the  main  factors  concerned  in  healthy  nutri- 
tion, it  is  to  their  diminution  or  overthrow  that  we  must  look  for  the 
actual  causes  of  degeneration  and  atrophy  ;  such  may  be  due  to  — 
(i)   A   deficient   supply   of   blood,    caused    by   actual   anaemia, 

disease  of  the  vessel  walls,  or  pressure  from  without. 
(2)    Deteriorated  quality  of  the  blood,  including  its  admixture 
with  certain  deleterious  substance  such  as  toxines,  alcohol, 
phosphorus,  lead,  etc. 


J  FATrV    DEGENERATION  3 

(3)  Impairment  of  the  powers  of  assimilation,  which  is  probably 

due  in  the  main  to — 

(4)  Impairment  or  loss  of  nervous  action,  and 

(5)  Inipairment  or  loss  o(  functional  activity. 

While  it  is  true  that  the  cause  of  any  degeneration  must  be 
sought  in  some  departure  from  the  normal  standard  of  nutrition, 
the  ultimate  causes  must  in  any  given  case  be  sought  in  tliose  con- 
ditions, constitutional  or  local,  to  which  such  departure  is  directly 
due.  These  causes  will  be  considered  under  each  form  of  degenera- 
tion. 

Varieties. — The  chief  forms  of  degeneration  met  with  are 
Fatty,  Albuminoid,  Calcareous,  Mucoid,  and  Colloid. 

FATTY    DEGENERATION 

In  fatty  Metamorphosis  the  albumen  of  the  cells  is  converted 
into  fat ;  in  fatty  Infiltration  fat  is  added  to  the  cells  or  is  deposited 
between  them,  but  is  not  made  from  the  albumen  of  the  part ;  the 
former  only  is  a  true  degeneration.  The  two  conditions  are  usually 
associated. 

Causes.  —  Fatty  metamorphosis  is  chiefly  met  with  in  pro- 
longed fevers,  chronic  suppuration,  and  wasting  diseases,  e.g.  cancer. 
Local  fatty  changes  may  be  induced  by  arterial  obstruction. 

Fatty  infiltration  may  result  from  an  excess  of  fat-forming  food, 
or  from  deficient  oxidation,  as  in  pulmonar)'  disease. 

Morbid  anatomy. — When  a  cell  is  undergoing  fatty  meta- 
morphosis, dark  spots  appear  in  its  

protoplasm ;  these  gradually  increase      /^^^  ffSb\        ''A 

in  size  and  coalesce,  the  centre  of  ^^^^  ^'  f^^^'  e  "^-^ 
the  oil  globule  is  then  seen  to  be  .  ^^^^  ^^^  'i^i;^ 
highly  refracting  andsurrounded  by  w""^^        eeSk.  «rv 

a  dark  margin.  Ultimately  the  cell  ^^^^  dm^S  y  °0^ff\ 
is  practically  converted  into  a  fat  2 1  W  ^91  i^V>\?r« 
cell,   the   whole   of  the  protoplasm        ^^^^  a^Q*9^ 

having  undergone  degeneration  ;  the    fig.  i.-Fatty  infiltration  and  fatty  de- 

rell    Sllhsenilt^ntlv    Hisinfecrnte«;    ^Fip-  generation  of  liver  cells  (Ziegler).     a,t; 

ceil    bUObCqUcnU)     aismtegraieb    ^^rig.  fatty  deposit  in  the  cells— infiltration  ; 

I>  ^. /)•        In  fatty  infiltration  the  cell  f-  ^^  <f./  f^tiy  degeneration  aad  dis- 

,  -  -     .  ,  integration  of  the  cells. 

contains  fat,  and  its  normal  proto- 
plasm is  simply  pushed  to  one  side  (Fig,  i,  b).      Fatty  infiltration  is 
only  of  pathological  importance  when  the  amount  of  fat  stored  up 
in  the  cells  is  large  enough  to  impair  their  functional  activity.      A 
part  which  is  the  seat  of  fatty  change  is  usually  increased  in  bulk  and 


4  MANUAL   OF  SURGERY  chap. 

weight,  but  both  may  be  diminished ;  the  consistency  is  altered,  the 
surface  is  greasy  and  fatty  in  appearance,  and  the  colour  is  pale  yellow. 

Surgical  importance  of  fatty  degeneration. — Since  pro- 
longed fever  and  suppuration  are  prominent  factors  in  the  produc- 
tion of  widespread  fatty  degeneration,  it  is  of  the  first  importance 
to  cut  short  these  processes  whenever  possible.  But  apart  from 
this  aspect  of  the  question,  fatty  changes  have  an  eftect  upon  the 
tissues  with  which  every  surgeon  should  be  familiar. 

The  heart,  if  fatty,  is  unfitted  for  the  administration  of  anaes- 
thetics, or  to  meet  any  shock  or  strain  thrown  upon  it  such  as  a 
capital  operation  entails. 

The  kidneys  are  rendered  incompetent,  and  hence  may  give 
out  after  an  operation,  especially  one  implicating  the  genito-urinary 
tract,  in  consequence  of  which  reflex  irritation  of  these  organs  may 
occur.  In  all  cases  of  renal  inadequacy  morphia  is  a  particularly 
dangerous  drug. 

Fatty  degeneration  may  occur  in  the  muscles  of  paralysed 
limbs,  in  wounded  nerves,  or  in  amputation  stumps.  In  the  last 
the  degenerative  change  is  a  preparatory  step  to  physiological 
atrophy ;  but  in  the  case  of  a  wounded  nerve  the  change  may  be 
arrested  and  a  restitutio  ad  integrum  brought  about  by  timely  suture 
of  the  divided  ends. 

The  arteries  which  may  require  the  attention  of  the  surgeon 
are  very  rarely  the  seat  of  primary  fatty  change,  which  is  usually 
limited  to  the  aorta. 

Atrophied  bones  contain  more  fat  than  natural,  which  fills  the 
widened  Haversian  spaces.  Fatty  change  is  a  marked  feature  of 
osteo-malacia. 

Inflammatory  products  may  become  fatty,  and  are  then  said 
to  be  caseated ;  when  such  a  process  occurs,  the  inflammation  is 
naturally  arrested.  Granulation  tissue  may  undergo  fatty  degenera- 
tion, provided  anything  interferes  with  its  due  nutrition. 

Any  new  growth,  especially  such  as  are  inadequately  supplied 
with  blood,  may  undergo  fatty  change,  as  is  almost  constantly  seen 
in  glandular  cancers. 

ALBUMINOID    DEGENERATION 

Causes. — This  form  of  degeneration  is  essentially  dependent 
upon  chronic  suppuration,  and  is  met  with  in  chronic  disease  of 
bones  and  joints,  phthisis,  congenital  and  acquired  syphilis,  and 
some  other  conditions. 


r  ALBUMINOID   DICGENERATIOM  5 

Morbid  anatomy. — The  change  is  specially  met  with  in  ilie 
liver,  spleen,  kidneys,  and  intestines.  It  begins  in  the  intima  of  the 
small  arteries,  spreads  to  the  capillaries  (Fig.  2,  b^  k^  i)  but  not  to  the 
veins,  and  ultimately  affects  the  adjacent  pr(){)er  cells  of  the  organ. 
The  cells  are  enlarged  and  rounded,  and  the  [)r()toplasm  is  gradually 
replaced  by  a  glistening  albuminoid  material,  the  whole  being  re- 
presented by  a  homogeneous  mass.  As  the  degeneration  advances 
the   tissue  is  converted  into  a  dense,   shining,   glue-like   material. 


f  / 


ui  I 


Fig.  2. — Amyloid  kidney  with  fatty  degeneration  (Ziegler).  a,  capillary;  b  and  k,  ai.iylold 
capillary;  c,  e, /,  fatty  epithelium;  d,  oil  globules;  g,  hyaline  casts;  A,  fatty  cails;  /, 
amyloid  arteriole ;  /,  cellular  infiltration  ;  ///,  round  cells  within  a  urinary  tubule. 

The  organ  is  enlarged,  heavy,  smooth,  elastic,  and  anaemic  in  con- 
sequence of  the  narrowing  of  the  blood-vessels  by  the  amyloid 
matter.  Fatty  degeneration  is  almost  always  associated.  The 
degenerate  material  is  known  as.lardacein,  but  is  never  found  in 
the  blood  as  such ;  Dickinson  regards  it  as  de-alkalised  fibrin, 
resulting  from  the  loss  of  potassium  salts  by  chronic  suppuration. 

When  treated  with  an  aqueous  solution  of  iodine,  albuminoid 
material  is  stained  a  reddish-brown  or  mahogany  colour ;  but  the 
most  delicate  test  is  by  methyl-violet,  which  stains  it  a  brilliant  red 
colour  and  the  unaffected  protoplasm  an  intense  blue. 


6  MANUAL  OF   SURGERY  chap. 

Sig"ns. — An  affected  organ  is  uniformly  enlarged  but  painless, 
and  there  may  be  evidence  of  interference  with  its  functions. 
When  the  kidneys  are  involved  there  is  albuminuria,  and  in  bad 
cases  dropsy  or  even  uraemia  may  result ;  diarrhoea  is  evidence  of 
albuminoid  change  in  the  intestines.  The  general  condition  of 
the  patient  is  aflected  not  only  by  the  chronic  suppuration,  but  by 
the  fact  of  albuminoid  degeneration ;  there  is  marked  anaemia, 
general  debility,  and  pallor  of  the  skin  with  cachexia. 

Treatment  is  preventive.  Chronic  suppuration  must  be 
arrested  by  means  applicable  to  the  individual  case.  In  some  cases 
this  will  effect  a  marked  improvement  in  the  condition,  even  if  the 
degeneration  is  advanced  ;  indeed,  if  the  cause  be  entirely  removed, 
practical  recovery  may  ensue.  The  diet  must  be  plentiful,  and 
rich  in  nitrogenous  material,  with  a  supply  of  fruit  and  green 
vegetables.  The  bicarbonate  and  citrate  of  potash  should  be 
given  internally,  in  view  of  the  great  diminution  of  the  potassium 
salts  in  the  tissues. 

COLLOID    AND    MUCOID    DEGENERATION 

These  conditions  are  chiefly  met  with  in  new  growths,  but  their 
causes  are  unknown.  The  colloid  change  affects  the  epithelial 
cells  and  is  met  with  in  some  forms  of  cancer,  especially  when 
affecting  the  abdominal  organs  ;  mucoid  degeneration  chiefly  attacks 
the  cellular  tissue.  The  mucoid  and  colloid  changes  are  usually 
associated.  Colloid  material  is  jelly-like  in  appearance  and  con- 
sistency, colourless  or  pale  yellow,  and  contains  albuminates  and 
mucin  with  sulphur;  the  last  substance  is  not  present  in  mucin. 
When  the  colloid  or  mucoid  change  is  quite  locaHsed,  a  cyst  con- 
taining the  material  is  formed.  The  so-called  colloid  cancer  is 
merely  a  cancer  which  has  undergone  colloid  degeneration. 


CALCAREOUS    INFILTRATION 

Calcification  consists  in  the  deposit  in  the  tissues  of  granules  of 
calciujn  phosphate  with  traces  of  calcium  carbonate,  and  of  the 
phosphate  and  carbonate  of  magnesia.  The  deposit  takes  place  in 
the  connective  tissue  and  the  cells. 

Causes. — It  is  probable  that  there  is  some  antecedent  change 
in  the  tissues  whereby  the  amount  of  carbonic  dioxide  is  lessened, 
and  hence  the  lime  salts  are  precipitated  from  the  fluids ;  in  some 
cases  the  change  appears  to  be  dependent  upon  an  excess  of  lime 


I  ATROPHY  7 

salts  in  ihc  blood,  c.j^.  ostco-malacia.  Calcificaiion  is  especially 
prone  to  affect  parts  of  low  vitality,  and  hence  is  met  with  in  the 
aged,  in  slowly  growing  new  growths,  in  cyst  walls,  and  in  caseous 
and  tubercular  foci.  When  the  change  is  advanced  the  tissue  may 
be  converted  into  a  dense  calcareous  mass,  which  has  not,  however, 
the  anatomical  structure  of  true  bone. 

In  advanced  age  calcareous  changes  in  the  arteries  and  ligaments 
are  common. 

Effects. — A  part  which  has  become  calcareous  may  practically 
be  considered  as  a  foreign  body,  incapable  of  undergoing  any 
vital  change,  but  sometimes  exciting  inflammation  in  its  neighbour- 
hood. The  effects  of  calcareous  changes  in  the  arteries  are  fully 
discussed  in  chap.  i.  vol.  iii. 

Atrophy 

Simi)le  atrophy  consists  in  wasting  of  a  tissue  without  any 
alteration  in  its  structure ;  in  some  cases  there  is  also  a  diminution 
in  the  number  of  the  component  elements  (Aplasia  or  Numerical 
Atrophy). 

Causation. — Atrophy  is  essentially  dependent  upon  failure  of 
nutrition,  and  consequently  is  often,  in  fact  usually,  associated  with 
degeneration,  especially  the  fatty  form.  Atrophy  differs  from 
degeneration  in  the  fact  that  there  is  no  chemical  change  in  the 
cells,  and  hence,  if  the  cause  be  removed  and  nutrition  be  re-estab- 
lished, complete  recovery  may  occur.  Atrophy  must  be  distinguished 
from  congenital  arrest  of  growth.  Atrophy  occurs  as  a  perfectly 
normal  process  in  advancing  age ;  in  the  sexual  organs  at  the 
climacteric,  and  in  the  thymus  gland  in  early  life.  General  atrophy 
may  be  merely  a  senile  change,  the  preparatory  step  to  death,  or  it 
may  be  dependent  upon  some  pathological  condition  inducing 
widespread  failure  of  nutrition.  Local  atrophy  is  due  to  some 
local  circulatory  disturbance,  to  functional  disuse,  to  constant  pres- 
sure, or  to  interference  with  the  nerve  supply  of  a  part.  Pressure 
induces  atrophy  by  lessening  the  blood  supply  and  diminishing 
functional  activity. 

Disuse  favours  atrophy  partly  because  the  tissue  is  deprived  of 
that  periodic  flux  of  blood  necessary  to  healthy  nutrition  ;  paralysed 
limbs  waste  (i)  from  lessened  blood  supply,  (2)  from  deficient 
trophic  impulse. 

Surgically,  atrophy  from  interference  with  the  nerve  supply  is 
seen  in  cases  of  injury  to  or  disease  of  nerves. 


8  MANUAL   OF  SURGERY  chap,  i 

Effects. — In  cases  of  simple  atrophy  the  part  retains  its  normal 
shape,  but  is  smaller  and  lighter  than  normal ;  but  as  fatty 
degeneration  is  usually  associated,  these  changes  may  be  masked, 
and  the  part  be  much  increased  in  Size  and  weight.  When  the 
component  cells  of  an  organ  atrophy,  it  may  become  much  denser 
than  natural,  from  an  undue  preponderance  of  connective  tissue. 
If  the  walls  of  a  hollow  viscus  atrophy  it  will  dilate  or  even  rupture. 
The  functional  activity  of  an  atrophied  structure  is  necessarily 
diminished,  according  to  the  degree  of  the  change. 

Treatment. — The  removal  of  the  cause  and  the  promotion  of 
healthy  nutrition  must  be  effected.  Atrophied  muscles  should  be 
electrically  stimulated,  their  use  encouraged,  and  nutrition  favoured 
by  cold  affusion  and  massage.  In  unreduced  dislocations  it  is  im- 
portant to  bear  in  mind,  during  attempts  at  reduction,  that  the  bone 
is  atrophied  and  weaker  than  natural. 

HVPERTROPHY 

Hypertrophy  implies  that  a  tissue  is  simply  overgrown ;  when 
the  component  elements  are  also  increased  in  number,  the  con- 
dition is  sometinaes  spoken  of  as  Hyperplasia  or  Xumerical  Hyper- 
trophy. The  mere  fact  of  enlargement  of  an  organ  does  not 
necessarily  imply  hypertrophy,  for  in  most  cases  the  enlargement  js 
dependent  upon  some  other  tissue,  thus  in  so-called  h3'pertrophy  of 
the  breast  the  greater  bulk  of  the  organ  is  formed  of  fat  (False 
Hypertrophy). 

Causes.  —  Hypertrophy  usually  occurs  in  response  to  some 
increased  need  for  growth  ;  thus  the  bladder  wall  hypertrophies 
in  response  to  additional  work  thrown  upon  it  by  stricture  of  the 
urethra,  or  if  one  kidney  be  rendered  practically  functionless,  the 
other  increases  in  size  to  meet  the  demands  upon  it ;  in  such  cases 
the  hypertrophy  is  said  to  be  compensatory. 

Intermittent  pressure  causes  hypertrophy  by  inducing  a  periodic 
afflux  of  blood  to  the  part,  as  is  commonly  seen  in  the  case  of 
corns,  or  thickening  of  the  epidermis. 

Occasionally  some  part  of  the  body,  especially  the  fingers  or 
toes,  is  congenitally  much  larger  than  normal,  from  causes  of  which 
we  are  ignorant. 


CHAPTER    II 

Local  Circulatory  Disturbanxes — Ixflam>l\tion 

ISCH^ML\ 

By  ischaemia  is  meant  a  diminution  of  the  blood  supply  of  a  part. 
This  condition  is  sometimes  clinically  spoken  of  as  anaemia,  a  term 
more  fittingly  reserYed  for  cases  in  which  the  blood  supply  is 
absolutely  cut  off,  or  to  indicate  a  general  state  due  to  poverty  of 
the  blood  itself. 

Causes. — Ischaemia  is  due  to  arterial  obstruction,  ^vh^ch  may 
be  produced  by  thrombosis,  embolism,  obliterative  arteritis,  ligature, 
or  pressure  from  without.  Ischaemia  of  nervous  origin  plays  an 
important  part  in  certain  pathological  conditions,  of  which  Ray- 
naud's disease  is  a  notable  example  (see  p.  82).  Ischaemia  is 
usually  a  temporary  state,  since  the  interference  with  the  circulation 
through  an  artery  is  speedily  compensated  for  by  collateral  circula- 
tion. Were  it  not  for  this  adaptability  of  the  vessels,  surgical 
operations  involving  the  ligature  of  large  and  important  vessels 
would  be  impossible. 

Chronic  ischaemia  is  common  in  advancing  life  when  calcareous 
and  atheromatous  changes  in  the  vessel  walls  are  pronounced,  for 
not  only  are  the  vessels  narrowed  and  the  walls  less  elastic  than 
normal,  but  in  such  cases  thrombosis  frequently  supervenes. 

Effects. — Diminution  of  the  blood-stream  limits  the  supply  of 
nutritive  material,  and  consequently  lowers  vitality. 

Deficient  nutrition  naturally  increases  the  proneness  of  the 
tissues  to  inflammation  and  other  pathological  lesions  of  a  trophic 
nature  ;  an  ischaemic  area  is  consequently  ready  to  respond  to  irrita- 
tion of  slight  intensity,  which  would  produce  no  effect  on  healthy 
tis-  ues ;  wounds  heal  with  difficulty  and  degeneration  soon  occurs. 


lo  MANUAL  OF   SURGERY  chap. 

Anemia 

The  term  anaemia  is  here  used  to  indicate  complete  cutting  off 
of  the  blood  supply  in  consequence  of  obstruction  of  the  vessels. 
The  causes  of  the  condition  are  the  same  as  those  of  ischaemia, 
but  since,  in  the  majority  of  cases,  collateral  circulation  is  speedily 
established,  anasmia  rarely  occurs.  Surgically,  complete  anaemia  is 
seen  in  cases  of  strangulation  of  the  bowel. 

Unless  quickly  relieved,  anaemia  inevitably  leads  to  gangrene. 

Active  Arterial  Hyperemia 

Active  hyperaemia  is  dependent  upon  relaxation  of  the  muscular 
coat  of  the  arteries,  which  may  be  induced  (i)  by  direct  stimula- 
tion causing  a  temporary  paralysis  from  injury;  (2)  by  the  influence 
of  the  central  nervous  system  excited  by  central  changes  or  reflex 
action  ;  (3)  by  injury  or  pathological  destruction  of  the  sympathetic 
nerve  filaments. 

Effects. — Active  hyperaemia  causes  redness  of  the  part,  in- 
creased rapidity  of  the  blood  stream,  with  some  elevation  of  the 
local  temperature,  and  a  sense  of  throbbing  and  fulness. 

Active  hyperccmia  may  be  beneficial,  as  in  the  healing  of 
wounds  and  the  absorption  of  inflammatory  products,  but  it  may 
also  pass  into  the  inflammatory  state. 


Passive  Hvper.emia — Venous  Congestion 

Causes. — Venous  congestion  maybe  due  (i)  to  a  defect  in  the 
propulsive  forces  of  the  circulation,  (2)  to  obstruction  in  the  veins. 

The  blood  is  driven  onward  by  the  action  of  the  heart  and  the 
elastic  recoil  of  the  arterial  walls,  and  hence  any  disease  impairing 
the  strength  of  these  forces  entails  venous  congestion  proportional 
to  the  diminution  of  power.  Mere  feebleness  of  the  heart's  action, 
independently  of  any  disease  of  its  structure,  may  cause  dangerous 
hypostatic  congestion,  as  is  frequently  seen  in  those  enfeebled  by 
disease  or  old  age. 

Venous  obstruction  may  be  due  to  thrombosis,  varicosity  of  the 
vessels,  or  pressure  from  without.  Valveless  and  unsupported 
veins,  especially  if  liable  to  periodic  engorgement,  are  very  prone 
to  be  the  seat  of  congestion,  e.g.  the  haemorrhoidal  plexus. 

Effects. — Venous  engorgement,  if  long  continued,  leads  to 
very  important  results,  and  is  one  of  the  most  potent  predisposing 


II  INFLAMMATION  ii 

causes  of  inflammation.  The  part  is  of  a  dusky  livid  colour,  and 
may  be  pigmented  from  the  disintegration  of  escaped  red  blood 
cells.  The  temperature  is  diminished,  and  there  is  a  sensation  of 
coldness,  numbness,  and  weight.  Oedema  varies  considerably  in 
amount,  according  to  the  extent  and  duration  of  the  congestion 
and  the  power  of  the  lymphatics  to  absorb  the  exuded  fluid.  The 
fluid  bathing  the  tissues  is  poor  in  albumen  and  fibrin,  contrasting 
with  that  poured  out  as  the  result  of  inflanmiation.  Chronic  con- 
gestion leads  to  induration  from  the  formation  of  new  fibrous  tissue, 
which,  by  the  pressure  it  exercises,  still  further  impedes  the  circula- 
tion. It  also  induces  chronic  inflammation  by  lowering  the  vitality 
of  the  tissues,  since  it  hinders  the  free  interchange  of  oxygen  and 
carbon  dioxide. 

Chronic  eczema  of  the  skin  and  ulceration  are  common  results, 
and  unless  the  congestion  can  be  overcome,  prove  most  intractable 
affections. 

Congested  veins  may  rupture,  but  rarely  bleed  much,  partly 
because  it  is  only  the  small  vessels  which  give  way,  and  partly 
because  the  feebleness  of  the  circulation  favours  coagulation  and 
spontaneous  arrest. 

Treatment. — The  line  of  treatment  must  depend  upon  the 
actual  cause  of  the  congestion.  If  the  force  of  the  circulation  is 
deficient,  the  heart's  action  must  be  encouraged,  by  cardiac  stimu- 
lants and  such  means  as  the  special  features  of  the  case  may  suggest. 

Pressure  on  the  veins  must  if  possible  be  removed.  The  circu- 
lation should  be  encouraged  by  the  elevated  position,  cold  douching, 
friction  and  massage,  and  the  parts  must  be  kept  warm.  Local 
bleeding  is  useful  in  some  cases.  The  use  of  diuretics,  saline 
purgatives,  and  diaphoretics  serves  to  unload  the  venous  system. 

Inflammation 

If  there  is  one  subject  in  General  Pathology  of  greater  import- 
ance than  another,  it  is  surely  that  of  the  Inflammatory  process. 
Travers  has  justly  said  that  "a  knowledge  of  the  phenomena  of 
inflammation,  the  laws  by  which  it  is  governed,  and  the  relations 
which  its  several  processes  bear  to  each  other,  is  the  keystone  to 
medical  and  surgical  science."  Its  common  occurrence,  numerous 
causes,  various  phases  and  results,  combine  to  render  it  a  subject 
of  extreme  interest,  and  one  with  which  the  surgeon  must  be 
thoroughly  familiar  if  he  is  desirous  of  understanding  the  greater 
part  of  practical  medicine  and  surgery. 


12  MANUAL  OF  SURGERY  chap. 

Inflammation  has  been  defined  by  Burdon-Saunderson  as  being 
"  the  succession  of  changes  which  occurs  in  living  tissue  when  it  is 
injured,  provided  that  the  injury  is  not  of  such  a  degree  as  at  once 
to  destroy  its  structure  and  vitaHty."  While  this  definition  leaves 
much  to  be  desired,  it  has  the  advantage  of  conveying  a  general 
concept  of  what  we  mean  by  inflammation  without  committing  us 
to  the  adoption  of  any  pathological  dogma.  The  series  of  events, 
the  sum  of  which  constitutes  the  inflammatory  process,  have  been 
repeatedly  followed  in  the  frog's  web  and  tongue,  the  rabbit's  ear, 
and  the  mesenter}-  of  both.  These  changes  are  similar  in  cold- 
and  warm-blooded  animals,  but  in  the  latter  greater  care  is  needful 
in  the  conduct  of  the  necessary  experiments. 

Physiological  data. — Under  normal  conditions  the  calibre 
of  the  arteries  may  be  dilated  or  contracted  under  the  influence 
of  the  vaso-motor  ner\-es,  either  as  the  result  of  central  or  reflex 
irritation.  Whether  any  peripheral  vaso-motor  ner\-ous  mechanisms 
exist  or  not  is  at  present  uncertain.  Contraction  of  a  vessel  is  due 
to  active  contraction  of  the  circular  muscular  fibres,  but  dilatation 
is  purely  passive.  Pathological  changes,  which  impair  the  nutrition 
of  the  arterial  coats,  afl"ect  their  elasticity  and  favour  or  produce 
dilatation. 

The  endothelial  cells  forming  the  walls  of  the  capillaries  are 
contractile,  and  hence  the  calibre  of  these  vessels  is  capable  of 
alteration.  The  cement  substance  between  the  capillary  endothelial 
cells,  when  stained  with  silver  nitrate,  exhibits  specks  and  slits  called 
stomata,  but  whether  or  not  these  are  reallv  holes  in  the  vessel  wall 
is  uncertain. 

The  blood  in  the  minuie  vessels  is  divided  into  two  zones — the 
axial  and  the  plasmatic ;  in  the  small  capillaries  the  differentiation 
between  axial  and  plasmatic  zones  is  not  so  evident  as  it  is  in  the 
small  arteries  and  veins.  The  axial  zone  consists  of  red  blood 
cells,  while  most,  but  not  all.  of  the  white  cells  are  found  in  the 
plasmatic  zone,  the  rate  of  flow  of  which  is  much  less  than  that  of 
the  axial  current.  The  white  corpuscles  exhibit  amoeboid  move- 
ments, and  roll  lazily  along  in  close  contact  with  the  vessel  wall. 
Under  normal  condiiions  the  red  blood  cells  remain  discrete,  but 
when  their  vitality  is  lowered  they  adhere  to  one  another  and  thus 
offer  increased  resistance  to  the  blood  flow. 

The  fluid  parts  of  the  blood  are  constantly  filtering  through  the 
capillary  and  venous  walls,  irrigating  the  tissues  and  being  absorbed 
again  by  the  lymphatics.  A  few  leucocytes  also  escape  and  wander 
outside  the  vessels.     Xo  exudation  takes  place  from  the  arteries. 


II  INFLAMMATION  13 

Etiology. — Predisposing"  causes  to  disease  are  those  conditions 
which,  by  inii)airing  the  vitality  and  hence  the  resisting  power  of 
the  tissues,  lay  them  open  to  morbid  processes  under  slight  provo- 
cation which  more  favourable  and  healthy  conditions  would  enable 
them  to  withstand.  The  conditions  essential  to  the  maintenance 
of  healthy  nutrition  have  already  been  alluded  to  in  considering  the 
degenerations  (p.  2),  and  further  special  causes  of  circulatory  dis- 
turbance have  been  mentioned  in  connection  with  fschaemia  and 
congestion  (pp.  9,  10).  The  predisposing  causes  of  inflammation 
must  be  sought  in  some  purely  local  state,  or  in  a  general  consti- 
tutional predisposition,  e.g.  the  Strumous  Diathesis.  Chief  among 
these  causes  are  to  be  noted : — 

(i)  A  deficiency  in  the  supply  of  arterial  blood. 

(2)  Venous  congestion,  and  consequent  stagnation  of  the  blood- 

stream and  failure  of  removal  of  the  waste  products  of 
metabolism. 

(3)  Impurity  of  the  blood  or  deficiency  in   its   quality,   either 

from  accumulation  of  waste  material  {e.g.  renal  disease), 
the  admixture  of  poisons  (e.g.  alcohol),  or  insufficient  and 
improper  food  so  frequently  associated  with  bad  hygienic 
surroundings. 

(4)  Interference  with  the  normal  nervous  supply  and  trophic 

influences,  e.g.  acute  bed-sores  and  perforating  ulcer. 

The  general  predisposing  causes  may  be  due,  as  in  the  case  of 
the  gouty  or  strumous  diathesis,  to  some  congenital  and  often 
hereditary  vice  of  the  tissues,  or  to  acquired  conditions  such  as 
may  be  induced  by  the  abuse  of  alcohol  or  by  unhealthy  occupa- 
tions or  surroundings. 

Exciting"  causes. — Anything  capable  of  inducing  inflammation 
is  spoken  of  as  an  "  irritant,"  but  it  is  necessary  to  this  end  that  such 
irritant  shall  act  with  a  certain  intensity,  and  for  a  certain  time; 
these  depending  upon  the  presence  or  absence  of  predisposing 
causes.  If  the  intensity  of  the  irritant  be  great,  it  may  kill  the 
part  to  which  it  is  applied,  but  the  dead  part  will  be  surrounded  by 
a  zone  of  inflammation  occurring  in  the  tissues  near  enough  to  feel 
the  effects  of  the  irritant,  but  sufficiently  remote  to  remain  alive. 
This  is  well  seen  in  the  production  of  an  eschar  by  the  actual 
cautery. 

Irritants  of  slight  intensity  may,  when  the  tissues  are  unhealthy, 
i.e.  predisposed,  excite  widespread  inflammation,  sometimes  fraught 
with  dangerous  consequences.  Every  surgeon  is  familiar  with  the 
fact   that   even    simple    operations  may  have  disastrous  results  in 


14  MANUAL    OF  SURGERY  chap. 

drunkards,  diabetics,  or  in  those  suffering  from  renal  disease  and 
some  other  general  states. 

iMechanical  causes,  such  as  wounds,  friction,  and  tension,  are 
common  factors  in  inducing  inflammation,  and  some  of  these  at 
least  are  capable  of  being  guarded  against  by  the  surgeon.  The 
avoidance  and  relief  of  tension  is  of  the  utmost  importance  in 
surgical  practice,  with  a  view  to  preventing  or  arresting  inflam- 
mation. If  the  tension  of  the  exudate  in  an  inflamed  part  is  great 
and  is  not  relieved,  it  tends  to  aggravate  the  condition,  besides 
causing  intense  suffering.  Some  mechanical  irritants  arise  within 
the  body  itself  {e.g.  calculi  or  sequestra),  or  may  have  been  em- 
bedded in  the  tissues  for  a  long  time  without  having  caused  any 
harm  {e.g.  bullets,  needles,  splinters)  j  in  these  cases  the  inflam.ma- 
tion  is  conservative  in  its  object,  the  result  being  the  extrusion  of 
the  foreign  body.  It  is  generally  believed  that  in  such  cases  the 
resulting  inflammation  is  dependent  upon  the  presence  of  micro- 
organisms, which  have  gained  entrance  to  the  seat  of  the  foreign  body. 

Heat  and  cold  beyond  certain  limits  (within  which  they 
exercise  a  beneficial  effect  upon  the  tissues)  may  excite  inflam- 
mation by  inducing  vascular  disturbance.  Any  chemical  substance 
having  irritating  properties,  such  as  the  strong  mineral  acids,  caustic 
alkalies,  and  certain  vegetable  substances,  will  excite  a  definite 
degree  of  inflammation  proportional  to  the  extent  of  their  applica- 
tion. All  the  above  causes  are,  however,  of  comparative  insignifi- 
cance as  compared  with  the  irrftating  effects  of  micro-organisms 
and  their  toxines,  for  a  full  account  of  which  the  reader  is  referred 
to  the  chapter  on  Bacteriology  (p.  87). 

Varieties. — Inflammation  is  classified  according  to  its  cause, 
extent,  duration,  and  the  essential  feature  of  the  phenomenon. 

I.  Cause. — Inflammations  may  be  traumatic,  gouty,  rheumatic, 
tubercular,  syphilitic,  etc.,  according  to  the  constitutional  condition 
underlying  the  process.  When  no  definite  cause  can  be  assigned, 
the  process  is  sometimes  said  to  be  idiopathic.  The  distinction 
between  simple,  septic,  and  infective  inflammation  is  of  the  greatest 
importance. 

By  simple  inflamtnation  we  mean  that  which  is  not  dependent 
upon  any  essential  poison,  and  which  is  consequently  always  limited 
and  never  severe. 

A  septic  iiifiamviation  is  one  dependent  upon  the  irritation  pro- 
duced by  the  chemical  products  of  decomposition  brought  about  by 
micro-organisms;  the  process  is  proportional  to  the  dose  of  the 
irritant,  and  ceases  with  its  removal  (p.  102). 


II  ACUTE   INI  LAMMATION  15 

Infective  inflaminafions  are  due  to  the  presence  of  pathogenic 
organisms,  and  may  be  locally  or  generally  infective,  according  to 
their  manner  of  spreading  in  the  tissues  (p.  103). 

2.  Extent. — Local  inflammation  is  dependent  upon  some  simple 
cause  which  acts  temporarily  on  healthy  tissues. 

Spreading  inflammation  is  due  to  invasion  of  the  tissues  or 
blood-stream  by  micro-organisms.  A  spreading  inflammation  may 
be  excited  in  one  of  the  following  ways : — 

(i)  The  tissues  may  be  soaked  with  the  irritating  products  of 
decomposition,  the  organisms  not,  however,  spreading  in 
them. 

(2)  Organisms  of  an  infective  nature  may  invade  the  tissues  by 

continuity,  as  in  the  case  of  phagedaena. 

(3)  Organisms  may  locally  invade  the  tissues  and  also  spread 

by  the  lymph  paths  to  the  neighbouring  lymphatic  glands, 
e.g.  cellulitis. 

(4)  The  true  general  infective  inflammation  is  due  to  infective 

organisms  which  may  not  only  spread  locally,  but  which, 
by  finding  their  way  into  the  blood-stream,  either  directly 
or  through  the  lymph  channels,  become  capable  of  exciting 
secondary  inflammatory  centres  at  distant  parts. 
For  further  information,  the  reader  is  referred  to  the  chapter  on 
the  Infective  Processes  (p.  102). 

3.  Duration. — Inflammation  may  be  acute,  subacute,  or  chronic, 
according  to  the  nature  of  the  cause,  the  duration  of  its  action, 
and  the  natural  resistance  or  proneness  of  the  afi'ected  tissues. 

4.  Nature  of  the  phenomena. — Inflammation  may  be  adhesive, 
i.e.  the  poured-out  lymph  organises  and  new  tissue  results,  as  in  the 
union  of  wounds ;  or  it  may  be  suppurative,  ulcerative,  or  gangren- 
ous. The  term  phlegmonous  implies  that  the  local  condition  is 
very  acute,  the  course  being  rapid  and  often  ending  in  sloughing. 
Catarrhal  inflammation  attacks  mucous  surfaces  and  is  described  at 
p.  2>(i. 

The  terms  sthenic  and  asthenic  are  referred  to  at  p.  31,  foot- 
note. 

ACUTE    INFLAMMATION 

The  phenomena  of  inflammation. — On  the  application  of 
an  irritant,  the  vessels  in  the  affected  area  dilate.  In  some  cases 
dilatation  is  preceded  by  initial  contraction,  which  is  quite  transitory 
in  its  nature  and  of  no  importance  as  regards  the  ensuing  changes. 


i6 


MANUAL  OF  SURGERY 


CHAP. 


Dilatation  does  not  affect  arteries,  veins,  and  capillaries  in  an  equal 
degree,  the  arteries  showing  the  greatest  enlargement  and  the 
capillaries  the  least.  In  consequence  of  this  dilatation  the  general 
vascularity  of  the  part  is  considerably  augmented,  and  numerous 
small  vessels  which,  on  account  of  their  minuteness,  were  before 
unnoticed,  spring  into  prominence. 

Coincident  with  this  general  dilatation  there  is  increased  velocity 
of  the  blood-stream,  soon  followed,  however,  by  marked  retardation 


Fig.  3. — Veins  and  capillaries  from  the  mesentery  of  a  frog,  after  exposure  for  several  hours. 
The  axial  stream  of  red  blood  cells  is  in  circulation  ;  the  leucocytes  have  collected  along  the 
vessel  walls  and  are  wandering  into  the  connective  tissue  of  the  mesentery  (diapedesis). 
(Billroth's  Surgety.) 

culminating  in  complete  stasis,  which  is  preceded  by  oscillation  as 
the  velocity  of  the  flow  is  temporarily  increased  during  the  cardiac 
systole.  If  the  inflammation  is  severe  and  lasts  long  enough,  stasis 
is  followed  by  thrombosis. 

The  leucocytes,  separated  from  the  axi  stream,  crowd  the 
plasmatic  layer,  line  the  vessel  wall,  and  move  slowly  along  during 
systole.  This  disposition  of  the  white  cells  and  their  escape  from 
the  vessel,  as  below  described,  is  chiefly  seen  in  the  venules  (Fig.  3); 
in  the  small  arteries  and  capillaries  they  are  not  so  numerous,  and 
do  not  form  such  a  continuous  layer  in  the  plasmatic  zone ;  more- 
over, they  are  mixed  with  red  cells,  which  predominate  in  number. 


II 


ACUTK  INFLAMMATION 


The  leucocytes  escape  through  the  walls  cf  the  veins  and 
capillaries  (diapedesis).  If  a  small  vein  is  closely  watched,  it  will 
be  seen  that  minute  projections  are  visible  on  its  outer  surface,  and 
that  these  correspond  to  leucocytes  in  the  interior;  in  the  course 
of  time  these  irregularities  of  outline  become  more  evident,  the 
leucocyte  being  proportionately  less  so.  In  j)oint  of  fact,  the 
leucocyte  is   actually  passing   through   the   wall,   to  which,   having 


Fig.  4.— Inflamed  omentum  (Zlegler).  a,  fibrous  tissue ;  h,  epithelium ;  c,  arter>' ;  a,  vein  with 
leucocytes  along  its  wall ;  e,  migrating  and  migrated  leucocytes ;  /,  desquamating  and 
degenerating  epithelium  ;yi,  proliferating  epithelium  ;  ^,  escaped  red  blood  cells. 

escaped,  it  is  at  first  attached  by  a  minute  process,  but  soon 
wanders  freely  into  the  surrounding  tissues.  Numberless  leucocytes 
thus  escape  and  infiltrate  the  tissues.  Red  corpuscles  also  escape  in 
small  numbers  in  consequence  of  the  intravascular  pressure,  but  being 
non-motile,  they  remain  in  close  proximity  to  the  vessel  from  which 
they  have  passed  unless  carried  to  distant  parts  by  the  fluid  exudate 
(Fig.  -  4,  g).  Diapedesis  is  confined  to  the  veins  and  capillaries  ; 
it  does  not  occur  from  the  arteries,  and  ceases  with  stasis.  Coin- 
cident with  diapedesis  there  is  an  escape  of  fluid  exudate  which 
bathes  the  tissues.     This  fluid  exudate,  mixed  with  the  leucocytes, 

VOL.  I  ^' 


1 8  MANUAL   OF  SURGERY  chap. 

is  known  as  inflammatory  lymph.  It  differs  from  that  which 
normally  bathes  the  tissues,  in  that  it  is  richer  in  albumen ;  it  also 
rapidly  and  firmly  coagulates  in  the  tissues,  the  serum,  as  it 
separates  from  the  coagulum,  being  taken  up  by  the  lymphatics. 
The  precise  nature  of  the  inflammatory  exudate  is  not  always  the 
same,  its  composition  varying  with  circumstances  concerning  which 
we  are  not  as  yet  fully  informed.  The  more  vigorous  the  health  of 
the  individual,  the  more  fibrinous  and  readily  coagulable  is  the 
exudate,  whereas  in  the  weak  and  enfeebled  the  fibrin  is  deficient 
in  quantity. 

The  seat  of  the  inflammation  also  modifies  the  exudate ;  thus 
in  inflammation  of  mucous  membranes,  sero-purulent  exudation  is 
met  with ;  while  in  that  of  serous  membranes,  firmly  coagulable 
fibrinous  exudation  is  common.  The  cause  of  the  inflammation 
has  also  some  influence  in  determining  the  nature  of  the  exudate. 
Sometimes  the  efl'usion  is  chiefly  serous  and,  although  containing 
fibrin,  does  not  show  any  tendency  to  coagulate ;  such  is  the 
case  in  rheumatic  synovitis  or  hydrocele.  Such  a  condition  is 
favourable,  since  coagulation  of  the  inflammatory  product  prevents 
its  ready  absorption  ;  fluidity,  per  contra^  favours,  or  at  least  does 
not  hinder  it.  The  ordinary  sero-fibrinous  exudate  varies  in  the 
relative  amount  of  fibrin  and  cells.  All  inflammatory  effusions 
may  be  mixed  with  more  or  less  blood,  especially  if  the  inflamma- 
tion occurs  as  the  result  of  injury,  or  in  those  of  debilitated  health, 
aad  notably  in  scurvy  and  haemophilia.  Inflammatory  effusion 
may  be  mixed  with  the  normal  secretion,  if  any,  of  the  part 
inflamed ;  thus  in  the  case  of  mucous  membranes,  mucus  is 
present,  or  in  that  of  a  joint,  synovium. 

Effect  upon  the  tissues. — The  effect  upon  the  fixed  tissue-cells 
of  the  inflamed  part  varies  with  circumstances,  but  in  all  cases  the 
inflammatory  exudate  causes  pressure  upon  them,  and  this,  coupled 
with  the  vascular  stasis,  necessarily  entails  loss  of  vitality  which 
may,  unless  the  process  be  arrested,  lead  to  destruction.  Death 
of  the  tissues  may  also  be  due  to  the  strength  of  the  irritant,  or  to 
its  direct  corrosive  action.  The  fixed  cells  do  not  multiply  during 
the  height  of  the  inflammatory  process  ;  but  when  this  has  sub- 
sided, and  repair  or  resolution  sets  in,  they  do  so  and  give  birth  to 
phagocytes  and  new  tissue  elements. 

Short  of  death,  the  cells  may,  from  nutritive  disturbances, 
undergo  degenerative  changes,  softening,  and  absorption,  their 
place  being  taken  by  the  inflammatory  exudate. 

Behaviour  and  fate  of  the  exudate. — The  albuminous  fluid 


ALU  IE   IXILAMMATION 


19 


exudate  which  infiltrates  the  tissues  in  an  inflamed  area  speedily 
forms  a  dense  coagiilum,  clotting  being  favoured  by  the  altered 
vitality  of  the  tissues  and  by  the  presence  of  the  numberless 
leucocytes,  many  of  which  are  broken  down,  and  hence  free  the 
fibrin-ferment.  The  further  away  the  exudate  gets  from  the  point 
of  irritation  the  loss  is  the  liability  to  coagulation,  and  the  fluid  is 
absorbed  by  the  lymphatics.  When  clotting  occurs,  the  fibrine 
and  leucocytes  entangled  in  its  meshes  form  dense  inflammatory 
lymph  which,  on  removal  of  the  irritant  and  the  consequent  arrest 
of  the  inflammation,  gradually  becomes  absorbed. 

According    to    Metchnikoff    and    the    phagocytic    theory,    the 


Fig.  5. — Anthrax  of  pigeon  (an  animal  only  slightly  susceptible  to  the  disease)  to  show  the  stapes 
of  destruction  of  bacilli  by  phagocytes,  i,  macrophage  from  exudati'^n  from  the  eye  ot 
refractory  bird  ;  2,  macrophage  from  muscle  of  region  of  inoculation  of  bird  that  succumbed  ; 
3,  4,  5,  microphages  from  the  eye  twenty-seven  hours  after  inoculation  ;  a,  a,  unaltered 
bacilli  ;  b^,  b"^,  b^,  bacilli  becoming  more  and  more  degenerated  and  indistinct ;  c,  c,  debris  of 
bacilli.     (Allbutt's  System  0/ Medicitu,  after  Metchnikoff.) 


escaped  leucocytes  crowd  round  the  noxious  agents  (usually  micro- 
organisms) and  engage  in  a  war  of  supremacy  with  them,  and  also 
remove,  by  ingestion,  any  dead  cells  or  other  matter  {e.g.  blood 
clot)  which  may  be  present  (Fig.  5).  While  all  pathologists  agree 
that  the  leucocytes  can  perform  this  latter  office  of  scavengers, 
many  dispute  their  power  to  remove  living  organisms,  or  at  any 
rate  deny  that  this  action  is  the  raison  d^etre  of  their  crowding  into 
the  inflamed  area. 

As  regards  the  ultimate  fate  of  the  leucocytes,  Metchnikofl^ 
asserts  that,  having  accomplished  their  purpose  and  destroyed  the 
micro-organisms,  they  themselves  fall  a  prey  to  large  phagocytes 
born  of  the  fixed  cells  of  the  part  and  the  endothelial  cells  of  the 


20  MANUAL   OF   SURGERY  chap. 

lymphatics.  Many  of  the  leucocytes  die  and  become  disintegrated 
during  this  war  for  supremacy,  their  remains  serving  as  pabulum  for 
the  still  living  phagocytes. 

Explanation  of  the  phenomena — Pathology. — At  the 
present  time  pathologists  are  divided  as  to  the  precise  interpretation 
to  be  put  upon  the  facts  observable  in  inflamed  areas. 

While  one  school,  following  the  teaching  of  Cohnheim,  lays  the 
responsibility  primarily  on  changes  in  the  vessel  walls,  Metchnikoff 
and  his  disciples  assert  that  inflammation  is  due  to  phagocytic  re- 
action on  the  part  of  the  leucocytes.  To  use  IMetchnikoff's  own 
words :  "  The  primiwi  7uovens  of  inflammation  consists  in  a  phago- 
cytic reaction  on  the  part  of  the  animal  organism.  All  the  other 
phenomena  are  accessory  to  this  process,  and  may  be  regarded  as 
means  to  facilitate  the  access  of  phagocytes  to  the  injured  part." 
The  blood-vessels,  to  damage  of  which  Cohnheim  attributed  the 
inflammatory  process,  are,  according  to  Metchnikoff,  not  necessary 
for  its  production,  although  the  vascular  disturbance  materially 
assists  by  bringing  phagocytes  ^  to  the  injured  area.  Ziegler,  oppos- 
ing ^letchnikoff' s  views,  says  that  "  The  phagocytosis  which  occurs 
in  the  course  of  an  inflammation  is-a  purely  accidental  phenomenon, 
which  is  brought  about  for  the  simple  reason  that  motile  cells 
happen  to  be  present,  together  with  a  material  capable  of  being 
ingested  by  them."  The  theory  of  phagocytosis  and  its  relation  to 
the  inflammatory  process  will  be  fully  discussed  later  (p.  97). 

Inflammation  must  doubtless  be  regarded  as  a  physiological 
rather  than  a  pathological  process ;  it  is  the  sum  of  those  changes 
which  are  consequent  on  irritation,  and  which  have  for  their  object 
the  removal  of  the  offending  materies  7norbi ;  this  being  accom- 
plished, all  the  phenomena  of  inflammation  disappear. 

The  initial  contraction  of  the  blood-vessels,  which  may  occur 
immediately  on  receipt  of  the  injury  inducing  the  inflammation,  arises 
from  direct  stimulation  of  the  muscular  coat ;  the  subsequent  dila- 
tation is  purely  passive,  and  is  due  to  paralysis  from  injury.  While 
paralysis  from  direct  injury  to  the  vessel  wall  is  the  chief  cause  of 
the  vascular  dilatation  at  the  point  of  action  of  the  irritant,  reflex 
nervous  irritation  or  local  nervous  mechanisms  play  a  part  in 
causing  the  vascular  dilatation,  especially  in  those  vessels  remote 
from  the  seat  of  irritation.  The  increased  velocity  of  the  blood- 
stream in  the  inflamed  area  is  due  to  the  fact  that  all  the  vessels 
are  not  equally  dilated.     The  amount  of  blood  brought  to  the  part 

^  Phagocytes  are  cells  derived  from  the  leucocytes  and  endothelium  of  the  vessels 
and  lymphatics  (see  p.  98). 


II  ACUTE   INFLAMMATION  21 

by  the  widely  dilated  arteries  must  flow  more  quickly  in  order  to 
pass  through  the  capillaries,  which  show  but  little  alteration  in  size. 

Retardation  of  the  stream  and  subsequent  stasis  cannot  be  due 
to  diminution  of  the  propelling  force,  since  no  such  diminution  is 
present ;  indeed,  the  force  of  the  heart-beat  is  usually  increased, 
i'he  vessels  being  dilated,  the  size  of  their  lumen  cannot  give  rise 
to  increased  local  resistance,  and  yet  there  is  such  an  increase.  In 
accordance  with  the  supposition  that  all  the  changes  in  inflamma- 
tion are  due  to  changes  in  the  vessel  walls,  retardation  and  stasis 
are  looked  upon  as  consequences  of  some  chemico-physiological 
change  in  the  vessel  walls,  whereby  the  accumulation  of  leucocytes 
and  massing  of  red  cells  into  rouleaux  is  favoured,  thus  increasing 
friction  and  offering  a  mechanical  impediment  to  the  blood  flow. 

Diapcdesis  is  due  to  the  inherent  amoeboid  activity  of  the 
leucocytes,  aided,  perhaps,  by  increased  intravascular  pressure. 
According  to  Cohnheim,  the  escape  of  leucocytes  and  lymph  is 
dependent  upon  the  altered  state  of  the  vessel  wall,  whereas 
Metchnikoff  regards  it  as  the  essential  feature  of  the  inflammatory 
process,  and  dependent  upon  an  attractive  influence  (positive 
chemiotaxis)  exercised  on  the  cells.  In  support  of  his  contention, 
the  latter  authority  points  out  that  diapedesis  does  not  always 
occur.  Thus  he  instances  tuberculosis  :  If  an  animal  be  inoculated 
with  the  bacillus  under  the  skin,  inflammation  with  diapedesis  and 
the  formation  of  extravascular  tubercle  occurs ;  but  if  the  inocula- 
tion be  intravascular,  the  leucocytes  gather  round  the  bacilli  within 
the  vessel  and  intravascular  tubercles  result.  In  fact,  the  leucocytes 
collect  wherever  the  noxious  irritant  is  present. 

The  fluid  exudate,  rich  in  albumen,  escapes  in  consequence  of 
the  increased  vascular  tension  and  the  alteration  in  the  vessel 
walls ;  under  normal  conditions,  albumen  does  not  pass  through 
the  vessel  w'alls,  which  exert  a  selective  influence  on  the  filtrate, 
but  during  inflammation  the  vitality  of  the  tissues  is  lowered  and 
consequently  no  bar  is  offered  to  the  escape  of  albumen. 

Termination  of  acute  inflammation. — As  the  inflammatory 
process  is  merely  the  succession  of  changes  occurring  in  the  tissues 
in  response  to  some  form  of  irritation,  its  duration,  extent,  and 
method  of  termination  necessarily  vary  with  the  nature  of  such 
irritant.  As  soon  as  the  exciting  cause  has  been  removed,  the 
inflammatory  process  is  arrested ;  in  mild  cases  this  happens  before 
any  appreciable  damage  has  been  inflicted,  and  the  part  is  com- 
pletely restored  (Resolution) ;  in  more  severe  cases  some  destruction 
of  tissue  occurs  and  repair  must  follow  (Granulation,  Organisation) ; 


2  2  MANUAL   OF  SURGERY 


CHAP. 


in  the  severest  forms  this  destruction  is  accompanied  by  the  forma- 
tion of  pus  (Suppuration,  Ulceration),  and  perhaps  appreciable 
portions  of  tissue,  being  completely  deprived  of  blood,  die  en  masse 
(Sloughing  and  Gangrene). 

It  must  not  be  forgotten  that  the  essential  nature  of  the  cause 
is  not  the  only  factor,  although  by  far  the  most  important  one,  to 
be  reckoned  with  in  forming  an  opinion  as  to  the  progress  of  the 
inflammation,  for  a  good  deal  depends  upon  the  state  of  the  tissues 
themselves.  In  weakly  tissues  an  irritant  of  slight  intensity  may 
occasion  considerable  inflammatory  action  and  consequent  damage, 
whereas  the  same  irritant  would  not  appreciably  affect  healthy 
tissues,  or  at  most  would  only  induce  a  mild  form  of  inflammation 
speedily  terminating  in  resolution. 

As  an  example  we  may  instance  the  special  liability  to  destruc- 
tive inflammation  in  congested  parts  and  in  patients  suffering  from 
diabetes,  and  the  well-known  facts  of  predisposition  of  individuals 
to  certain  diseases  due  to  micro-organisms,  e.g.  erysipelas. 

Resolution. — When  the  inflammatory  process  has  been  of  mild 
intensity  and  the  irritant  inducing  it  has  been  removed,  the  vitality 
of  the  tissues  and  vessels  is  restored  and  a  status  quo  ante  is  brought 
about.  The  nutritive  equilibrium  of  the  vessel  walls  is  regained, 
and  hence  they  resume  their  normal  tone  and  power  of  contraction 
and  dilatation  under  the  vaso-motor  mechanism.  The  circulation 
is  re-established,  the  corpuscles  nearest  the  still -flowing  blood 
gradually  breaking  away  from  the  stagnant  blood  until  the  stream 
in  the  previously  inflamed  area  returns  to  the  normal. 

The  vessel  walls  regain  their  filtering  action  and  no  longer 
permit  the  free  escape  of  lymph  and  leucocytes,  whatever  exudation 
is  allowed  being  kept  \\'ithin  normal  bounds.  As  regards  the  in- 
flammatory exudate,  the  fluid  part  and  many  of  the  white  cells  are 
quickly  absorbed  by  the  lymphatics ;  any  red  cells  which  may  have 
escaped  disintegrate  and  are  removed  by  phagocytes  ;  the  coagulated 
fibrin  and  such  cells  as  are  entangled  ]n  its  meshes  are  removed 
by  the  fixed  phagocytes  derived  from  the  endothelial  cells.  Some- 
times the  ajiiount  of  exudation  is  so  great  that  its  removal  by 
absorption  is  very  slow  or  incomplete  ;  in  such  cases  surgery  may 
assist,  as  in  pleural  effusion  or  synovitis,  by  drawing  off  the  super- 
abundant fluid.  If  the  coagulated  exudate  is  very  large  in  quantity, 
the  area  of  inflammation  may  remain  indurated  for  a  long  time,  or 
the  exudate  may  undergo  fatty  changes  leading  to  caseation.  This 
process  will  be  more  fully  mentioned  in  dealmg  with  chronic  in- 
flammation. 


II 


ACUTE   INFLAMMATION 


23 


Granulation  and  organisation.  —  When  inflanimation  lias 
caused  destruction  of  tissue  by  absorption,  or  as  the  result  of 
suppuration,  and  when  the  process  itself  has  been  arrested,  repair 
of  the  damaged  tissue  sets  in. 

Organisation  may  be  a  beneficial  or  harmful  process,  according 
to  the  situation  in  which  it  occurs  ;  beneficial,  if  it  repairs  a  loss  of 
tissue,  as  in  the  healing  of  a  wound  or  abscess ;  harmful,  if  the  new 
1  issue  replaces  one  of  higher  physiological  rank,  whose  functioiiS 
the  new  connective  tissue  is  incapable  of  fulfilling. 


^    d 


d  a 

Fig.  6. — Formation  of  scar  tissue  and  new  bile  ducts  in  chronic  hepatitis  (Ziegler).  a,  a\,  hepatir 
lobules ;  <J,  new  scar  tissue ;  c,  old  bile  ducts ;  d^  newly-formed  bile  ducts  ;  ^,  round-celled 
innltration. 

Repair  is  said  to  be  perfect  when  the  new  tissue  is  similar  in 
its  chemical,  physical,  and  physiological  properties  to  that  which  it 
replaces.  Man's  power  of  perfect  repair  is  far  inferior  to  that  of 
many  of  the  lower  animals ;  thus,  lizards  will  completely  regenerate 
their  tails  and  fimbs,  and  some  worms  have  yet  more  perfect  powers 
of  regeneration. 

When  repair  is  imperfect,  the  loss  to  the  economy  varies  within 
the  widest  limits ;  thus,  if  a  portion  of  the  breast  substance  has 
been  destroyed  and  replaced  by  connective  tissue,  the  harm  done 
is  practically  not  felt,  since  the.  breast  cannot  be  regarded  as  a  very 
important  organ  ;  but  if  a  similar  condition  were  to  affect  the  con- 
ducting paths  of  the  spinal  cord  or  any  other  organ   of  vital  im- 


2  4  MANUAL  OF   SURGERY  chap. 

portance,  the  resulting  loss  would  be  disastrous  and  widespread ; 
between  these  two  instances  many  gradations  of  mischief  will  readily 
occur  to  the  mind  (see  p.  34). 

For  an  account  of  the  process  of  repair,  the  reader  is  referred 
to  chap.  ii.  vol.  ii. 

Suppuration — Destructive  inflammation. — If  the  irritant  is  of 
sufficient  intensity  to  cause  necrosis  of  any  cells,  the  part  speedily 
becomes  infiltrated  with  leucocytes.  The  dead  area  softens,  the 
cells  disintegrate,  and  a  minute  abscess  is  formed  which  gradually 
increases  in  size.      The  process  is  fully  described  at  p.  38. 

The  occurrence  of  suppuration  is  in  the  main  to  be  regarded 
as  unfavourable ;  in  some  cases,  however,  it  is  beneficial  to  the 
patient,  as  being  one  of  Nature's  methods  of  freeing  the  body  from 
such  injurious  irritants  as  a  foreign  body  or  sequestrum. 

Local  signs  of  acute  inflammation. — The  association  of 
redness,  swelling,  heat,  and  pain  with,  in  many  cases,  functional 
derangement,  is  characteristic  of  inflammation ;  one  or  more  of 
these  signs  may  be  met  with  under  other  conditions,  but  all  are 
present  in  the  inflammatory  process,  although  they  do  -not  neces- 
sarily manifest  themselves  in  equal  degree. 

Redness  is  dependent  upon  vascular  engorgement,  and  hence  is 
most  marked  in  parts  of  high  vascularity,  but  is  not  \-isible  in  the 
case  of  internal  inflammation.  The  intensity  of  the  colour  and  its 
distribution  vary.  In  the  skin  the  whole  area  is  the  seat  of  the 
blush,  but  in  mucous  membranes  the  individual  vessels  may  show 
up  as  bright  streaks  and  the  surface  is  said  to  be  injected.  In 
very  intense  inflammation,  some  of  the  redness  is  dependent  upon 
the  escape  of  red  cells  and  capillary  haemorrhage.  If  the  inflam- 
mation has  reached  that  stage  in  which  the  stagnant  blood  is 
thrombosed,  pressure  will  not  diminish  the  colour ;  in  other  cases 
the  blood  is  driven  onwards,  but  the  blush  returns  as  soon  as  the 
pressure  is  relieved.  The  margin  of  the  redness  -gradually  fades 
into  the  normal  colour  of  the  part,  except  in  certain  cases  {e.g. 
cutaneous  erysipelas)  in  which  it  is  sharply  outlined.  With  sub- 
sidence of  the  inflammation  the  redness  disappears,  but  some  pig- 
mentation may  remain  if  red  cells  have  escaped  from  the  vessels. 

Swelling"  is  due  to  the  inflammatory  exudate  and,  in  a  slight 
degree,  to  the  vascular  engorgement.  In  health,  the  normal 
exudation  from  the  vessels  is  taken  up  by  the  lymphatics,  and  during 
inflammation  this  absorption  is  increased ;  but  as  the  exudate 
coagulates  in  the  tissues,  its  complete  removal  by  the  lymphatics 
becomes   impossible.       The   amount   of  exudate   is  dependent  on 


II  ACUTE   INFLAMMATION  25 

the  intensity  of  the  inflammation  and  the  natural  vascularity  of 
the  part.  In  lax  vascular  tissues,  e.g.  the  scrotum  or  face,  the 
swelling  is  often  enormous,  since  there  is  a  large  quantity  of 
exudate  and  but  little  tension.  In  dense  fibrous  structures  such  as 
tendon  -  sheaths,  the  exudate  is  at  high  tension,  and  hence  the 
swelling  is  not  marked.  The  exudation  naturally  travels  in  the 
direction  of  least  resistance,  permeating  the  connective  tissue  of  the 
part,  and,  in  the  case  of  cavities,  being  poured  into  the  sac ;  in  the 
lungs  it  fills  the  alveoli,  and,  on  serous  membranes,  forms  a  tough 
layer  of  lymph  with  serous  accumulation.  The  degree  of  swelling 
in  all  these  cases  is  necessarily  subject  to  great  variation,  and  is 
sometimes  practically  inappreciable. 

Heat — The  local  heat  is  due  to  the  increased  afflux  of  arterial 
blocJd.  The  degree  of  heat,  as  complained  of  by  the  patient,  is 
merely  a  measure  of  sensation,  and  is  greater  than  that  indicated 
by  the  surface  thermometer,  for  although  there  is  certainly  an 
appreciable  rise  in  the  local  temperature,  yet  this  never  reaches  the 
temperature  in  the  rectum. 

Pain. — Pain  is  due  to  pressure  of  the  inflammator}'  exudate, 
and,  in  open  wounds,  to  exposure  of  the  ners'ous  filaments  or 
to  their  irritation  by  the  chemical  products  of  decomposition ;  in 
some  cases  neuritis  adds  much  to  the  suffering.  Individual 
susceptibility  also  plays  an  important  part.  As  pressure  is  the 
main  cause  of  the  pain,  the  latter  will,  other  things  being  equal,  be 
dependent  upon  the  amount  of  the  exudate,  but  it  is  also  very 
materially  influenced  by  the  natural  nerve  supply  of  the  part.  In 
lax  tissues,  where  the  exudate  can  easily  distend  the  parts  without 
causing  much  tension,  pain  may  be  ver}-  slight  in  spite  of  great 
swelling  and  a  plentiful  nene  supply. 

On  the  other  hand,  the  pain  caused  by  inflammation  of  dense 
structures  is  severe,  as  is  seen  in  the  case  of  whitlow,  periostitis,  or 
orchitis. 

The  pain  of  inflammation  is  usually  dull,  aching,  and  throbbing 
in  character;  it  is  increased  by  the  dependent  position  which 
favours  engorgement  of  the  inflamed  part,  and  is  worse  at  night, 
probably  because  the  ner\ous  system  is  more  impressionable. 
Very  often  the  pain  has  a  '•  tensive "  character,  conveying  to  the 
patient  the  idea  that  something  is  pent  up  to  which  exit  should  be 
given. 

Altepation  in  function  is  due  (i)  to  the  altered  vital  condition 
of  the  inflamed  tissues,  (2)  to  the  mechanical  impediment  caused  by 
the  accumulated  exudate,  and  (3)  to  the  pain  caused  in  parts  con- 


2  6  MANUAL  OF   SURGERY  chap. 

cerned  with  movement.  The  function  of  the  part  is  generally 
diminished  or  lost  for  the  time  being  ;  in  other  cases  it  is  per- 
verted. Thus,  the  bladder  has  two  distinct  functions — it  serves  to 
hold  urine  and  also  to  expel  it ;  but  when  its  walls  are  inflamed, 
the  viscus  can  only  hold  a  very  small  amount  of  urine,  while  its 
expulsive  efforts  are  frequent  and  strong.  Similarly,  in  the  case  of 
the  special  senses,  the  function  is  not  only  diminished  but  perverted, 
so  that  there  are  auditory,  visual,  or  other  hallucinations  according 
to  the  sense  affected. 

The  constitutional  symptoms  of  acute  inflammation. — 
Inflammation  of  slight  intensity,  especially  if  attacking  an  unim- 
portant part,  is  not  accompanied  by  general  disturbance  ;  but  when 
a  certain  degree  of  severity  is  reached,  certain  symptoms  make 
themselves  manifest,  the  sum  of  which  constitutes  the  febrile  state. 
The  degree  of  fever  and  the  gravity  of  the  general  disturbance  vary 
with  circumstances ;  the  physiological  importance  of  the  part,  the 
intensity  and  extent  of  the  mischief  and,  above  all,  its  cause  being 
the  most  important  factors.  The  young  and  the  aged,  and  those 
of  a  nervous  temperament,  are  liable  to  high  fever  from  slight 
causes. 

As  regards  situation,  inflammation  of  the  lungs,  brain,  kidneys, 
tonsils,  and  ear  is  accompanied  by  severe  constitutional  symptoms ; 
whereas  a  similar  affection  of  a  joint  or  bone  occasions  but  little 
disturbance.  The  precise  nature  of  the  process  is  of  the  greatest 
importance,  a  simple  inflammation  producing  much  less  serious 
effects,  even  when  widespread,  than  does  one  which  is  dependent 
on  some  infective  organism,  or  is  associated  with  putrefaction  and 
retention  of  the  discharges,  for  in  such  cases  the  absorption  of 
toxines  produces  more  or  less  severe  general  disturbance. 

The  physiology  of  heat. — In  warm-blooded  animals  the  pro- 
duction and  loss  of  heat  are  so  regulated  that  a  fairly  uniform 
temperature  is  maintained.  Heat  is  produced  by  oxidation  and 
combustion,  the  greater  quantity  being  formed  in  the  muscles, 
abdominal  viscera,  and  brain,  i.e.  in  parts  exhibiting  great  physio- 
logical activity. 

About  75  per  cent  of  the  heat  is  lost  by  evaporation  and  radia- 
tion from  the  skm,  i8  per  cent  by  the  lungs,  and  the  remaining  7 
per  cent  by  warming  the  excreta. 

The  maintenance  of  a  normal  temperature  is  dependent  upon  a 
balance  being  struck  between  production  and  loss,  which  is  brought 
about  by  the  influence  of  the  nervous  system.  Experiments  and 
clinical  observation  tend  to  show  that  there  is  a  thermogenic  centre 


II  ACUTE   INFLAMMATION  27 

in  the  brain,  probably  in  the  pons.  The  production  of  heat  mu^t 
also  be  dependent  upon  trophic  influences,  themselves  of  nenous 
origin ;  its  loss  may  be  increased  or  diminished  by  alterations  in 
the  breathing,  or  in  the  vascular  engorgement  of  the  skin. 

The  production  of  fever. — If  the  amount  of  heat  produced  is 
in  e.xcess  of  that  which  is  lost,  the  patient  becomes  febrile ;  such  a 
disproportion  is  dependent  upon  increased  heat  production,  and 
not  upon  diminished  loss.  That  production  is  increased  is  proved 
by  the  fact  that  although  during  the  febrile  state  the  patient  takes 
less  food,  yet  the  discharge  of  urea  and  CO.,  and  the  rapid  wasting 
of  the  body  indicate  increased  oxidation ;  moreover,  during  the 
febrile  state,  the  patient  loses  much  more  heat  than  under  norrnal 
conditions. 

How  is  this  increased  production  of  heat  brought  about  ?  Un- 
doubtedly through  the  intervention  of  the  nervous  system,  the  heat- 
producing  centres  being  stimulated  by  certain  substances  circulating 
in  the  blood,  and  which,  from  their  capability  of  inducing  fever,  are 
called  "pyrogenic." 

In  simple  inflammations,  such  as  may  occur  in  cases  of  fracture 
or  subcutaneous  injury,  and  in  which  there  can  be  no  question  of 
septic  or  infective  influences,  the  pyrogenic  material  is  the  fibrin- 
ferment  which,  as  we  have  already  seen,  is  contained  in  the  serum, 
being  set  free  by  disintegration  of  some  of  the  leucocytes.  Fever 
dependent  upon  this  cause  is  usually  slight  and  transient,  and  if 
the  exuded  serum  is  ver)'  small  in  quantity,  or  is  drained  away,  no 
fever  results  ;  under  contrary-  conditions  the  temperature  may 
remain  high,  rapidly  falling,  however,  as  soon  as  the  serum  is  given 
free  exit. 

Fibrin  -  ferment  is  by  no  means  the  only  pyrogenic  material, 
nor  is  it  a  very  important  one.  The  products  of  putrefactive  de- 
composition and  of  pathogenic  organisms  (Ptomaines  and  Toxines) 
are  strongly  pyrogenic,  causing  high  fever  with  proportionate  con- 
stitutional disturbance. 

Fever  due  to  the  action  of  non-pathogenic  or  putrefaction  fungi 
is  directly  proportional  to  the  dose  of  the  poison  absorbed,  and  if 
this  be  drained  away  and  the  v.ound  cleansed,  the  temperature 
quickly  falls ;  but  in  the  case  of  the  pathogenic  organisms  such 
removal  is  often  impossible,  and  so  long  as  the  organisms  live  and 
flourish  in  the  tissues,  so  long  are  their  toxines  absorbed  and  excite 
fever. 

AMiether  these  poisons  cause  fever  by  acting  on  the  thermogenic 
centres,  or  whether,  circulating  in  the  blood,  they  act  directly  on 


2Z  MANUAL  OF   SURGERY  chap. 

the  tissues  independently  of,  or  in  association  with,  the  nervous 
system,  cannot  at  present  be  determined. 

The  symptoms  associated  with  fever.  —  In  any  disease 
associated  with  fever,  no  matter  what  its  precise  nature  or  seat, 
there  are,  in  addition  to  the  symptoms  which  these  latter  may 
determine,  certain  constitutional  effects  due  to  the  fever  itself,  such 
effects  being  as  a  rule  proportional  in  severity  to  the  height  of  the 
temperature.  In  cases  where  the  temperature  rises  gradually,  the 
symptoms  develop  gradually ;  but  if  the  rise  of  temperature  is 
rapid — as  in  many  of  the  infective  processes — the  constitutional 
disturbance  is  equally  sudden.  Fever  may  be  continuous,  re- 
mittent, or  intermittent,  and  the  symptoms  follow  much  the  same 
course. 

A  sudden  onset  is  usually  ushered  in  by  shivering  or  by  a  more 
or  less  severe  rigor,  followed  by  profuse  sweating  and  rapid  dechne 
of  the  temperature,  which  may,  however,  quickly  rise  again.  In 
young  children  a  convulsive  attack  takes  the  place  of  a  rigor.  When 
the  onset  is  gradual,  the  patient  may  complain  of  alternate  shiver- 
ing and  flushing,  with  a  sense  of  general  malaise. 

In  moderate  degrees  of  fever  (103^  F.)  the  skin  is  flushed, 
hot  and  dry,  sometimes  perspiring ;  the  face  is  flushed  and  often 
anxious,  the  eyes  are  bright  and  suffused,  and  the  alae  nasi  may 
move  slightly  with  respiration. 

Alimentary  trad. — The  tongue  is  moist  and  coated,  especially 
along  the  dorsum,  with  a  creamy  white  fur.  The  mouth  is  clammy, 
and  there  is  considerable  thirst  with  loss  of  appetite,  nausea,  and 
perhaps  vomiting.     The  bowels  are  constipated. 

Urinary  system. — The  urine  is  scanty  and  concentrated.  The 
specific  gravity  is  increased,  the  colour  heightened,  and  on  cooling, 
the  urine  is  rendered  cloudy  from  precipitation  of  urates.  The 
amount  of  urea  and  nitrogenous  bodies  is  increased,  but  the 
chlorides  are  diminished. 

Respiratory  system. — The  respiration  is  slightly  increased  in 
rapidity,  but  is  shallow.  Marked  difficulty  points  to  some  affection 
of  the  lungs  or  pleura.      The  breath  is  often  offensive. 

Circulatory  syste?n. — The  pulse  rate  is  increased,  usually  about 
5-10  beats  for  every  degree  of  fever;  increase  beyond  this  ratio 
indicates  £ardiac  failure.  The  pulse  is  bounding,  soft,  compressible, 
and  often  distinctly  dicrotic. 

Nervous  system. — There  is  frontal  headache,  irritability  of 
temper,  wakefulness  at  night  and  occasionally  slight  delirium. 
Should  delirium   supervene,   headache  ceases,   except  in   cases   of 


II  ACUTE   INFLAMMATION  29 

meningeal  or  cerebral   mischief  in   which  the   patient  complains  of 
headache  throughout. 

When  fever  is  continued  for  some  days,  or  when  it  runs  as  high 
as  104°  or  105"  F.,  the  symptoms  are  essentially  the  same, 
although  some  are  modified.  Nervous  prostration  is  more  marked, 
and  delirium  is  usually  present  at  night  ;  the  tongue  becomes  dry 
and  cracked,  and  the  lips  and  teeth  are  loaded  with  sordes,  the 
jxitient  being  too  feeble  to  close  the  mouth.  The  facial  appearance 
indicates  severe  illness ;  the  expression  is  anxious,  the  eyes  dull  and 
lustreless,  and  the  complexion  leaden. 

In  very  severe  cases,  especially  in  those  due  to  some  acute 
infective  process,  the  patient  falls  into  the  "typhoid"  state,  a  con- 
dition of  serious  import. 

Nervous  prostration  is  extreme ;  the  patient  lies  on  his  back, 
sunk  down  in  the  bed,  the  mouth  is  half-open,  the  eyelids  drooping, 
and  the  face  has  a  dull,  leaden,  expressionless  aspect.  The  tongue  is 
deeply  coated  with  a  dry  brown  fur,  here  and  there  deeply  cracked, 
and  sordes  accumulate  round  the  lips  and  gums. 

There  is  profound  mental  apathy,  and  although  the  patient  may 
usually  be  temporarily  roused,  he  speedily  relapses  into  indifference 
as  to  his  surroundings.      He  takes  fluid  nourishment  well. 

This  apathetic  condition  is  accompanied  by  low  muttering 
delirium  (Typhomania). 

Profuse  sweating  and  diarrhcea  are  common,  and  add  to  the 
general  prostration  ;  the  patient  exhales  a  disagreeable  earthy  odour, 
and  his  hands  have  often  a  withered,  shrunken  appearance  and 
brown  discoloration. 

As  the  end  approaches,  there  is  muscular  tremulousness,  sub- 
sultus,  and  risus  sardonicus ;  the  extreme  nervous  and  muscular 
prostration  is  further  evidenced  by  incontinence  of  faeces  and  urine. 
Finally  coma  supervenes  and  death  closes  the  scene. 

General  prognosis  of  fever.  —  The  prognosis  necessarily 
depends  upon  the  actual  cause  inducing  fever,  but  at  the  same  time 
the  course  the  temperature  runs  may  in  itself  be  matter  for  anxiety. 

In  the  case  of  continuous  fever  a  sudden  extra-elevation  usually 
indicates  the  occurrence  of  some  additional  mischief  or  complication, 
e.g.  suppuration  ;  a  sudden  fall  may  mean  convalescence,  or  else  a 
complication  inducing  extreme  collapse,  e.g.  perforation  of  the  gut. 

A  temperature  of  105°  F.  is  in  itself  a  serious  matter;  should 
hyperpyrexia  (106°  F.)  set  in,  the  case  will  almost  certainly  terminate 
fatally. 

To  be  of  any  real  value,  at  least  two  thermometric  observations 


30  MANUAL  OF  SURGERY  chap. 

must  be  taken  daily  (morning  and  night).  In  some  diseases,  ^.^^. 
tubercle,  the  degree  of  fever  is  so  slight  that  the  thermometer  alone 
can  detect  it,  its  persistence  indicates  that  the  disease  is  in  active 
progress,  although  the  mischief  may  be  so  insidious  that  no  other 
sign  is  certainly  diagnostic. 

The  prognosis  as  to  the  duration  of  fever  depends  upon  the 
circumstances  of  the  case,  and  whether  or  not  these  are  such  as  to 
permit  of  our  getting  rid  of  the  supply  of  pyrogenic  material ;  thus, 
in  fever  due  to  septic  absorption,  free  drainage  and  flushing  with  an 
antiseptic  lotion  will  speedily  reduce  the  temperature. 

Treatment  of  acute  inflammation. —  Preventive.  —  In 
surgical  practice  the  preventive  treatment  of  acute  inflammation  is 
a  matter  of  paramount  importance.  It  has  already  been  stated 
that  the  most  important  and  harmful  class  of  irritants  are  the 
micro-organisms  and  their  products,  and  hence  the  exclusion  of 
these,  or  the  removal  of  their  products  by  the  practice  of  anti- 
septics, is  of  the  first  importance  (see  chap.  i.  vol.  ii.). 

It  is  necessary,  moreover,  before  performing  any  operation,  to  see 
that  the  general  health  of  the  patient  and  the  vitality  of  the  tissues 
to  be  operated  on  are  good,  otherwise,  even  an  aseptic  operation 
may  lead  to  unfortunate  consequences.  When  applying  any 
apparatus,  e.g.  splints,  great  care  must  be  taken  not  to  cause 
injurious  pressure  or  tension,  both  of  which  are  exciting  causes  of 
inflammation. 

Curative. — The  tissues  have  a  natural  tendency  to  spontaneous 
cure,  provided  they  are  relieved  from  injurious  influences  ;  hence,  if 
the  cause  of  the  inflammation  can  be  removed,  the  process  quickly 
subsides.  This  is  unfortunately  not  always  possible,  and  we  have 
therefore  to  adopt  local  and  constitutional  remedies  for  promoting 
local  and  general  vitality,  and  so  aiding  recovery.  A  knowledge  of 
the  causes  of  any  pathological  process  and  its  phenomena  is  the 
basis  of  all  rational  treatment.  It  is  very  important  to  estimate 
correctly  the  relative  degree  of  mischief  dependent  on  local  and  on 
general  causes ;  otherwise  we  may  apply  treatment  in  the  wrong 
direction.  Thus,  constitutional  treatment  would  be  valueless  in 
the  case  of  an  inflammation  dependent  on  local  irritation,  and 
conversely,  local  treatment  would  do  little  good  in  the  case  of  a 
syphilitic  sore,  unless  constitutional  remedies  were  also  prescribed. 

General  means  are  directed  towards  the  treatment  of  any 
dyscrasia  present,  or,  in  its  absence,  towards  the  maintenance  of  the 
patient's  health,  and  the  abatement  of  the  constitutional  symptoms 
during;  the  acute  inflammation. 


II  ACUTE   INFLAMMATION 


3^ 


Some  forms  of  inflnmmation  arc  successfully  combated  by  certain 
drugs  which  are  said  U)  ha\e  a  specific  action,  e.j{.  mercury  and 
iodides  in  syphilis,  salycine  in  rheumatism.  Unfortunately  the 
number  of  these  specifics  is  very  small. 

The  treatment  of  the  constitutional  effects  of  inflammation 
varies  according  to  the  strength  and  age  of  the  patient  and  to 
whether  the  signs  present  are  of  the  sthenic  or  asthenic  type.^ 

In  sthenic  cases  the  bowels  should  be  opened  and  kept  acting 
by  saline  aperients  with  a  view  to  promoting  a  free  flow  of  fluid 
into  the  intestinal  canal,  thus  diminishing  blood  pressure,  and  also 
to  removing  from  the  body  effete  material.  As  toxines  are 
eliminated  by  the  kidneys  and  the  skin,  the  secretion  of  urine  and 
sweat  should  be  encouraged  by  the  use  of  diuretics  and  diaphoretics  ; 
the  citrate  and  nitrate  of  potash,  Dover's  powder,  antimony  and 
aconite  are  the  most  useful  drugs  for  this  purpose.  All  preparations 
of  opium  must  be  given  with  great  care,  especially  if  there  is  any 
renal  mischief  If  the  inflammation  is  very  acute,  and  the  patient 
young  and  full-blooded,  bleeding  from  the  median  basilic  vein  may 
do  much  good,  notably  in  acute  pneumonia  and  inflammatory 
conditions  within  the  skull ;  but  bleeding  should  not  be  practised 
at  the  two  extremes  of  life,  when  the  loss  of  blood  is  badly  borne. 
Stimulants  are  rarely  required. 

In  asthenic  cases  the  main  indications  are  to  rid  the  system  of  any 
toxines  which  may  be  circulating  in  the  blood,  and  to  build  up 
the  patient's  strength.  Bleeding  must  never  be  resorted  to ;  and 
although  the  action  of  the  bowels,  skin,  and  kidneys  must  be  en- 
couraged, drugs  to  attain  this  end  must  be  cautiously  administered, 
as  their  too  free  use  further  taxes  the  patient's  failing  strength. 

Food  must  be  given  in  an  easily  digestible  and  concentrated 
form — chicken  and  beef  jelly,  Brand's  essence,  Liebig,  Carnrick's 
peptonoids,  and  Benger's  food  are  of  great  use.  Alcoholic  stimu- 
lants are  always  necessary,  and  narcotics,  especially  opium,  are 
indicated  by  the  great  nervous  prostration.  The  pulse  is  the  best 
guide  as  to  the  necessity  for  alcohol  If  the  heart  is  failing,  alcohol 
must  always  be  given  in  quantities  sufficient  to  increase  its  strength. 
As  a  rule,  nervous  prostration  and  cardiac  failure  go  together,  and 
the  effects  of  alcohol  in  inducing  sleep  and  improving  the  nervous 

^  No  very  accurate  definition  of  these  terms  can  be  given.  A  sthenic  inflamma- 
tion is  one  in  which  the  local  and  constitutional  signs  assume  an  active  form,  and, 
although  perhaps  running  a  severe  course,  are  strongly  combated  by  the  patient  ; 
asthenic  inflammations  are  specially  marked  by  intense  nervous  prostration  and 
the  rapid  onset  of  "  typhoid  "  symptoms,  the  patient  showing  little  or  no  recuperative 
or  resistant  power. 


32  MANUAL  OF   SURGERY  chap. 

tone  are  often  remarkable.  It  should,  as  a  rule,  be  held  in  reserve 
until  clearly  demanded  by  the  state  of  the  pulse,  and  when  its  object 
has  been  attained  the  quantity  should  be  diminished. 

By  clinical  experience,  and  by  that  alone,  will  the  surgeon  be 
able  to  adopt  the  happy  mean  between  the  depressant  and  stimulant 
line  of  treatment ;  and  it  is  to  the  constitutional  symptoms  that  we 
must  look  for  guidance.  A  failing  heart,  nervous  prostration,  and 
adynamia,  with  symptoms  merging  into  the  "typhoid"  state,  are 
indications  for  free  stimulation. 

During  convalescence  the  diet  must  be  generous,  and  malt 
liquors  may  be  given  with  advantage. 

Loeal  treatment. — Rest  is  one  of  the  most  important  thera- 
peutic agents  we  possess  ;  it  encourages  repair  and  healthy  nutrition, 
lessens  vascular  excitement,  and  favours  absorption  of  the  exudate. 
The  method  of  obtaining  rest  necessarily  varies  with  the  seat  of  the 
mischief.  Thus,  in  a  joint  we  employ  some  form  of  splint ;  for  the 
eye,  atropine  and  avoidance  of  light.  The  principle  remains  the 
same  in  all  cases,  although  the  methods  employed  are  as  diverse  as 
are  the  functions  of  different  parts  of  the  body. 

Position. — When  possible,  the  inflamed  part  should  be  raised, 
with  the  view  of  lessening  congestion,  and  favouring  the  return  of 
blood  and  lymph.  Patients  in  many  instances  voluntarily  raise  and 
rest  an  inflamed  part,  since  the  pain  is  thereby  much  diminished. 

Heat  may  be  employed  in  the  form  of  poultices,  hot  fomenta- 
tions, hot  baths,  or  by  enveloping  the  part  in  cotton  wadding. 
Whenever  there  is  an  open  wound,  hot  antiseptic  fomentations  or 
baths  should  always  be  the  method  adopted. 

Heat,  especially  combined  with  moisture,  causes  general  relaxa- 
tion of  the  tissues  and  dilatation  of  the  cutaneous  and  other  vessels, 
and  hence  relieves  congestion  of  the  inflamed  area,  favours  absorp- 
tion, diminishes  tension,  and  relieves  pain.  It  increases  exudation 
from  the  vessels,  and,  if  suppuration  be  imminent,  hastens  the  pro- 
cess ;  if  sloughs  are  present,  their  separation  proceeds  more  rapidly, 
as  heat  increases  the  vitality  of  the  tissues  and  so  favours  repair. 
Open  septic  wounds  are  rapidly  cleansed  by  hot  antiseptic  irrigation 
with  weak  boracic  solution  or  Condy's  fluid.  By  this  means  the 
putrefying  discharges  are  continuously  washed  away. 

Cold  may  be  applied  by  the  ice-bag,  Leiter's  tubes,  cold  irriga- 
tion, evaporating  lotions,  or  cold  compresses.  The  ice-bag  is  usually 
the  most  convenient  form.  Leiter's  tubes  are  very  useful  when  cold 
has  to  be  applied  to  the  head  or  spine.  Evaporating  lotions  are 
not  much  used,  as  they  require  constant  reapplication. 


II  CHRONIC    INFLAMMATION  33 

Cold  is  especially  useful  in  inflammation  of  the  central  nervous 
system,  and  in  acute  synovitis ;  it  should  be  continuous,  is  only  to 
be  applied  during  the  earlier  stages  of  the  inflammatory  process,  and 
never  when  suppuration  is  imminent.  Cold  diminishes  congestion 
and  exudation ;  but,  generally  speaking,  is  inferior  to  heat  as  a 
therapeutic  agent. 

Local  sedatives  2lXQ.  sometimes  employed  in  conjunction  with  moist 
heat,  but  their  beneficial  effect  has  perhaps  been  over-estimated, 
(ilycerine  and  extract  of  belladonna  in  equal  parts,  aconite,  opium, 
or  poppy-head  fomentations  are  the  usual  remedies. 

Local  astringents  are  very  useful  in  catarrhal  inflammation  of  the 
mucous  membranes  (see  p.  36). 

The  relief  of  local  tension  may  be  obtained  by  local  bleeding,  dry 
cupping,  or  by  free  incision  aided  by  elevation,  heat,  and  rest. 
Cupping  is  not  much  used  in  surgical  practice.  Leeches  are  useful 
in  very  acute  inflammation  with  threatened  suppuration.  They 
should  never  be  applied  to  any  part  where  there  is  no  resistant 
structure  against  which  pressure  may  be  employed  to  arrest  the 
bleeding ;  this,  if  very  troublesome,  may  be  stopped  by  the  applica- 
tion of  a  point  of  silver  nitrate,  or  by  acupressure.  Bleeding  by 
puncture  of  the  veins  is  sometimes  necessary  in  acute  orchitis. 

The  most  satisfactory  method  of  bleeding  to  relieve  tension  is 
by  incision,  which  allows  free  escape  of  the  inflammatory  exudate. 
This  treatment  is  especially  useful  in  periostitis,  cellulitis,  and  spread- 
ing inflammations  generally.  When  suppuration  has  occurred,  a 
free  incision  into  the  abscess  limits  the  destructive  process. 

CHRONIC    INFLAMMATION 

Etiologry. — The  causes  of  chronic  inflammation  are  of  the  same 
nature  as  those  inducing  the  acute  form ;  but  they  act  with  less 
intensity  and  over  a  longer  period  of  time,  and  whereas  acute  in- 
flammation is  much  more  dependent  upon  local  causes,  the  chronic 
form  is  due  in  the  main  to  general  constitutional  conditions,  such 
as  syphilis,  gout,  or  struma. 

The  chief  local  condition  favouring  chronic  inflammation  is 
passive  venous  congestion,  which  lowers  the  vitality  and  resisting 
powers  of  the  tissues  by  preventing  the  free  interchange  of  oxygen 
and  carbon  dioxide,  and  hence  favours  the  accumulation  of  waste 
and  deleterious  products. 

In  many  cases  chronic  inflammation  depends  upon  the  associa- 
tion of  several  causes,  each  in  itself  insufficient  to  induce  the  change. 
VOL.  I  P 


34  MANUAL  OF    SURGERY  chap. 

This  is  well  exemplified  in  the  case  of  chronic  ulcers  of  the  leg ; 
venous  congestion,  enfeebled  health,  slight  mechanical  injury,  such 
as  a  scratch,  and  too  often  neglect  and  uncleanliness,  combining  to 
produce  a  destruction  of  tissue  which  no  one  of  the  conditions  would 
have  caused  per  sc. 

The  process  and  its  results.  —  The  series  ot  changes 
characteristic  of  acute  inflammation  are  also  present  in  a  modified 
form  in  the  chronic  process.  The  stagnant  blood  frequently 
coagulates,  the  engorged  vessels  rupture,  and  the  blood  is  extrava- 
sated,  the  disintegrating  red  corpuscles  causing  subsequent  pig- 
mentation. The  exudation  is  mainly  cellular,  the  surrounding 
tissues  being  infiltrated  with  small  round  cells  derived  mainly  from 
the  leucocytes,  but  also  from  the  fixed  connective  tissue  cells. 

The  ultimate  result  depends  in  great  measure  upon  whether  the 
cause  be  simple,  infective,  local,  or  constitutional. 

Complete  resolution  sometimes  occurs ;  but  more  usually  some 
induration,  due  to  fibroid  overgrowth,  results.  Organisation  is 
common,  the  inflamed  part  being  occupied  by  new  scar  tissue  which, 
as  it  contracts,  exerts  injurious  pressure  on  the  proper  cells  of  the 
part  (Fig.  6,  p.  23).  The  latter  may  in  consequence  undergo 
fatty  degeneration,  atrophy,  and  ultimate  absorption,  e.g.  cirrhosis 
of  the  liver.  The  result  of  this  change  necessarily  varies  according 
to  the  seat  of  inflammation  and  the  importance  of  the  cells  thus 
replaced  by  new  connective  tissue. 

Organising  chronic  inflammation  of  the  skin,  subcutaneous  tissue, 
or  mucous  membranes  leads  to  thickening  and  induration.  Occur- 
ring in  the  intermuscular  cellular  planes,  it  may  bind  down  the 
muscles  and  tendons,  and  prevent  their  free  contraction,  and  may 
similarly  lead  to  adhesions  between  joint-surfaces  and  in  the  pleural 
and  peritoneal  cavities.  When  occurring  in  glandular  organs,  the 
secreting  cells  are  destroyed,  and  the  function  of  the  organ  is  pro- 
portionately impaired.  Organisation  in  or  round  the  walls  of  tubes 
or  ducts  causes  obstruction  of  the  lumen,  leading  to  stricture,  or  the 
formation  of  retention-cysts.  In  the  nervous  centres  the  most  seri- 
ous results  may  follow  if  the  nervous  elements  are  replaced  by  new 
connective  tissue. 

As  in  acute,  so  in  chronic  inflammation,  the  process  may  termi- 
nate in  death  of  the  tissues  leading  to  ulceration  or  abscess.  Chronic 
abscess  may  steadily  progress  until  it  bursts,  or  the  fluid  parts  may 
be  absorbed  and  a  caseous  mass  result ;  this  may  subsequently 
calcify,  and  remain  permanently  harmless,  or  excite  further  mischief 
at  a  later  date  (see  p.  48), 


II  CHRONIC   INFLAMMATION  35 

Signs  and  symptoms. — The  signs  of  chronic  inflammation 
are  similar  in  nature  to  those  of  the  acute  form,  hut  are  necessarily 
modified  in  degree.  The  colour  is  dusky,  livid,  and  cyanotic,  in 
place  of  the  bright  red  of  acute  inflanunation ;  pigmentation  is 
common,  owing  to  changes  occurring  in  the  hajmogiobin  set  free 
from  the  escaped  red  cells.  Swelling  is  the  most  characteristic  sign  ; 
it  is  never  very  great,  and  the  swollen  parts  are  dense,  hard,  and 
brawny  from  cellular  exudate  and  fibroid  overgrowth.  The  local 
iieat  is  not  perceptibly  increased,  nor  does  the  patient  complain 
of  it. 

Pain  is  less  acute,  and  has  not  the  throbbing  character  of  acute  in- 
flammation. It  is  rather  a  sense  of  aching,  tenderness,  and  indefinite 
neuralgia.  In  chronic  inflammation  of  dense  fibrous  structures,  or 
of  bone,  the  pain  may  be  very  severe.  In  some  cases  pain  is  caused 
by  implication  of  the  nerve  fibrils  in  the  fibroid  tissue,  and  if  there 
is  loss  of  substance,  e.g.  ulceration,  the  nerves  may  be  exposed, 
and  cause  acute  pain.  The  function  of  a  chronically  inflamed  part 
is  slightly  lessened  in  proportion  to  the  extent  of  the  mischief. 

The  constitutional  symptoms  of  chronic  inflammation  are  really 
those  of  the  dyscrasia  to  which  it  is  due.  In  simple  cases  there  are 
none  at  all.  If  suppuration  accompanies  the  process,  there  may  be 
nocturnal  elevation  of  the  temperature  by  one  or  two  degrees ;  and 
as  soon  as  the  abscess  is  opened,  hectic  fever  may  result  if  the  pus 
decomposes.  The  leading  symptoms  are,  in  the  majority  of  cases, 
dependent  upon  the  damage  inflicted  on  the  organ  by  the  fibroid 
induration. 

Treatment  of  chronic  inflammation.  —  General  treat- 
ment.— As  in  many  cases  chronic  inflammation  is  the  expression 
of  some  general  condition,  e.g.  syphilis,  the  constitutional  treatment 
is  of  primary  importance,  and  must  be  that  which  is  applicable  to 
the  dyscrasia  present. 

In  all  cases  the  general  health  and  hygienic  surroundings  must 
be  attended  to — tonics,  good  food,  cod-liver  oil,  maltine,  etc.,  being 
given.  Small  doses  of  mercury,  sometimes  combined  with  the 
iodides  of  ammonia,  potash,  or  soda,  are  often  serviceable  in  remov- 
ing inflammatory  induration  in  cases  not  necessarily  dependent  upon 
syphilis.  Arsenic,  strychnine,  iron,  quinine,  and  vegetable  bitters 
are  also  useful.  Calcium  sulphide  is  strongly  recommended  by 
some  in  chronic  tubercular  affections,  but  its  value  is  open  to 
question.  Change  of  air  and  scene  and  residence  in  some  watering- 
place  are  also  to  be  recommended. 

Local  treatment. — Any  local  exciting  cause  must  of  course  be 


o 


6  MANUAL   OF   SURGERY  chap. 


removed,  such  removal  being  often  all  the  treatment  necessary  ;  but 
in  many  cases  this  cannot  be  done,  and  means  must  be  adopted  to 
combat  the  inflammation.  Local  bleeding  and  the  application  of 
heat  are  seldom  used.  The  main  object  is  generally  the  improve- 
ment of  local  nutrition  by  encouraging  the  circulation,  and  hence 
unloading  the  congested  vessels.  The  principal  means  of  effecting 
this  are  rest,  the  elevated  position,  careful  bandaging  or  strapping, 
cold  douching  and  massage.  In  chronic  ulceration  due  to  varicose 
veins,  these  should  be  tied.  In  some  cases  the  employment  of 
counter-irritants  is  very  serviceable ;  they  presumably  act  by  draw- 
ing an  increased  supply  of  good  blood  to  the  part,  and  hence  favour- 
ing nutrition. 

Tincture  of  iodine  is  a  favourite  but  almost  useless  application ; 
if  used  it  must  be  made  to  blister  the  skin,  and  this  can  be  more 
readily  done  by  liquor  epispasticus.  Blistering  no  doubt  gives 
much  relief  in  some  cases,  e.g.  chronic  neuritis,  and  materially  helps 
absorption  of  inflammatory  fluid  as  in  hydrarthrosis;  but  in  many 
cases  blisters  are  useless.  When  used,  they  must  be  frequently 
repeated. 

The  actual  cautery  applied  to  the  superficial  parts  of  the  skin 
is  useful  in  chronic  neuritis,  arthritis,  and  some  rheumatic  affections. 
Free  incision  into  the  inflamed  tissues  frequently  does  much 
good,  especially  in  chronic  inflammation  of  bone  accompanied  by 
pain. 

Chronic  inflammation  of  mucous  surfaces  is  best  treated  by  the 
application  of  astringent  antiseptic  lotions. 

If  suppuration  occurs,  the  treatment  is  that  of  chronic  abscess 
(see  p.  49). 

CATARRHAL    INFLAMMATION 

Catarrhal  inflammation  attacks  mucous  membranes,  the  process 
occurring  in  the  sub-epithelial  structures.  The  epithelium  itself 
resists  destruction  (unless  the  process  be  very  severe,  or  the  irritant 
kills  it  outright),  while  the  vessels  beneath  dilate,  and  the  exudate 
is  poured  into  the  tissues.  Moderate  degrees  of  irritation,  while 
powerful  enough  to  excite  inflammation  of  the  sub -epithelial 
structures,  merely  stimulate  the  epithelium  itself,  the  cells  of  which 
multiply  with  great  rapidity  and  are  cast  off  in  large  quantities. 
Some  of  these  cells  contain  leucocytes  or  micro-organisms.  The 
escaped  leucocytes  pass  to  the  surface  between  the  epithelial  cells, 
so   that   there  may   be   definite   purulent   catarrh.     In  very  severe 


11  CHRONIC   INFLAMMATION  37 

inflammation  the  superficial  structures  arc  killed  and  ulceration 
ensues.  The  surface  of  the  mucous  membrane  is  deej)))'  congested 
and  injected  with  blood  ;  the  secretion  is  increased,  and  mixed 
with  it  are  leucocytes,  mucus,  and  desquamated  epithelium  cells  in 
various  stages  of  degeneration.  There  is  some  swelling,  but  little 
pain.  If  the  process  becomes  chronic,  there  is  considerable  thicken- 
ing, pigmentation,  and  ulceration  in  patches. 

Treatment. — The  discharges  must  be  washed  away  with 
antiseptic  astringent  lotions,  such  as  boric  acid,  Condy's  fluid,  alum, 
or  chlorate  of  potash.  Special  treatment  may  be  required  accord- 
ing to  the  seat  and  cause  of  the  mischief,  e.g.  bladder,  throat,  etc. 


CHAPTER    III 

Suppuration  and  Aescess 

Under  certain  circumstances  inflammation  may  terminate  in  death 
of  the  exudate  and  liquefaction  of  the  tissues,  with  the  formation  of 
pus.  Suppuration  may  be  acute  or  chronic,  localised  or  diffused, 
superficial  or  deep.  When  destructive  inflammation  occurs  in  a 
wound  or  on  the  surface  of  the  skin  or  mucous  membranes,  the 
discharge  escapes  and  appreciable  portions  of  tissue  may  die  en 
masse  ;  this  will  be  further  considered  under  Ulceration  and 
Sloughing  (see  chap.  iv.  p.  56).  When  pus  forms  in  the  deeper 
tissues  it  may  be  diff'used,  or  enclosed  in  a  cavity  forming  an  abscess. 

ACUTE    SUPPURATION ACUTE    ABSCESS 

Etiology. — Acute  suppuration  is  dependent,  probably  in  all 
cases,  upon  the  presence  and  action  of  pyogenic  organisms,  coupled 
with  a  certain  predisposition  of  the  tissues  which  enables  these 
organisms  to  thrive.  Pyogenic  organisms  may  be  present  in  the 
blood  cr  on  the  surface  of  the  skin  or  mucous  membranes  without 
inducing  suppuration,  and  indeed  they  are  constantly  so  present 
both  on  the  skin  and  mucous  membranes  and  in  our  surroundings. 

Suppuration  then  is  dependent  on  (a)  a  predisposition  of  the 
tissues,  (d)  the  action  of  organisms ;  but  the  relative  part  played  by 
these  two  factors  is  not  always  the  same.  If  the  dose  of  the  poison 
is  large,  or  the  virulence  great,  suppuration  will  ensue  in  tissues  but 
little  predisposed  to  its  occurrence ;  but  if  the  tissue-resistance  is 
feeble,  a  small  dose,  or  organisms  of  attenuated  virulence,  will  induce 
a  like  result. 

A.  Predisposition  of  the  tissues  is  brought  about  by  any  con- 
dition lowering  the  vitality  upon  which  their  power  of  resistance  to 


en 


.  in     ACUTE   SUPPURATION— ACUTE   ABSCESS 


39 


irritants  depends.  Enfeebled  health  from  advancing  years,  chronic 
alcoholism,  disease  of  the  prinue  vi(r,  especially  of  the  kidneys,  or 
some  constitutional  dyscrasia  diminish  the  vitality  of  the  body 
generally.  Local  resistance  may  be  impaired  by  heat,  cold,  chemi- 
cal irritation,  tension,  mechanical  injury,  or  inflammation.  Subcu- 
taneous injury  may  lead  to  inflammation  or  cause  rupture  of  small 
vessels  and  thereby  admit  into  the  tissues,  where  they  find  conditions 
favourable  to  growth  and  development,  any  organisms  which  may 
be  circulating  in  the  blood. 

Open  wounds  offer  a  ready  means  of  ingress  for  organisms 
which  may  be  at  hand,  and,  if  the  dose  be  strong  enough,  these  will 
excite  suppuration, 

B.  The    influence    of   pyog-enie   organisms.  —  Organisms   are 


Fig.  7. — Colony  of  streptococcus  er>-sipelatis  (Ziegler).  a,  streptococci  within  a  lymph  vessel 
b  grouped  together  partly  in  globular  masses  and  partly  in  chaplets  like  torula;  ;  c,  tissue 
round  the  lymph  vessel  with  pale,  non-staining  nuclei  ;  d,  vein  ;  e,  cellular  infiltration  ;/;  cells 
within  a  lymph  vessel. 

present  in  the  pus  of  all  acute  suppurations,  and  many  experiments 
have  shown  that  their  presence  is  not  merely  accidental,  but  is  the 
actual  cause  of  the  process.  Carre  induced  suppuration  and  large 
carbuncular  patches  on  his  arm  by  inunction  of  gelatine  cultiva- 
tions of  staphylococcus  pyogenes  aureus. 

Bockhardt,  Bumm,  and  many  others  have  similarly  demon- 
strated the  pyogenic  properties  of  this  and  other  organisms,  and  in 
each  case  the  organisms  were  found  in  the  pus  of  the  abscesses 
which  formed.  All  pyogenic  organisms  have  not  the  same  degree 
of  virulence,  nor  has  any  special  kind  the  same  virulence  under  all 
circumstances ;  nor,  again,  are  they  all  equally  common  in  acute 
suppuration,  as  will  presently  be  shown. 

Pyogenic  organisms  are  abundantly  present  everywhere,  and  may 
gain  entrance  to  the  body  by  wounds,  abrasions,  or  by  the  ducts  of 
the  skin  or  glands  opening  on  the  surface  {e.g.  the  breast) ;  they  may 
also  enter  the  blood  by  the  miicous  surfaces,  especially  if  these  be 


40 


MANUAL   OF   SURGERY 


CHAP. 


abraded  or  inflamed.  The  organisms  may  spread  by  the  lymphatics 
(Fig.  7,  p.  39)  or  by  the  blood-stream;  when  present  in  the  blood 
they  may  be  destroyed  and  excreted  by  the  kidneys  and  do  no  harm  ; 
but  should  they  meet  with  tissues  whose  vitality  is  impaired,  suppura- 
tion will  ensue.  In  some  cases,  masses  of  cocci  are  arrested  as 
emboli  in  the  capillaries  (Fig.  8)  and  (rest  favouring  their  growth 

and  activity)  local  points  of  suppuration 
ensue,  as  is  seen  in  the  formation  ot 
secondary  abscesses  in  pyaemic  infection. 
Anything  favouring  rest  and  lodgment  of 
the  organisms  in  the  vessels  or  tissues 
enables  them  to  act  effectually ;  thus, 
injury  accompanied  by  extravasation  of 
blood  containing  organisms  may  lead  to 
suppuration,  and  parts  in  which  the  cir- 
culation is  naturally  feeble  are  favourable 
Fig.  8. —  Colonies  of  micrococci  seats  of  invasion.  Morc  than  one  form 
TziegiV.)'  ^'^^'''  capuiaries,  ^f  organism  may  be  present  (mixed  infec- 
tion), and  in  some  cases  at  least  the 
virulence  of  the  poison  is  thereby  increased  \  thus,  experiment  has 
shown  that  acute  necrosis  in  rabbits  is  more  severe  if  staphylococcus 
pyogenes  aureus  and  albus  are  present  together,  than  if  either  is 
alone,  the  dose  in  each  case  remaining  the  same.  All  pyogenic 
organisms  possess  in  a  high  degree  the  power  of  peptonising 
albumen,  and  hence  they  bring  about  liquefaction  of  the  tissues 
and  prevent  coagulation  of  the  inflammatory  exudate  :  they  also 
give  rise  to  toxines,  to  the  absorption  of  which  the  constitutional 
symptoms  are  due. 

Pyogenic  org'anisms. — Staphylococcus  pyogeties  aureus  is  the 
most  common.  It  is  abundant 
everywhere,  and  is  found  in  more 
than  70  per  cent  of  cases  of  acute 
suppuration.  It  is  present  in 
acute  abscesses,  boils,  carbuncles, 
osteomyelitis,  infective  periostitis, 
ulcerative  endocarditis,  septic  in- 
fection, etc.  It  liquefies  gelatine, 
and  in  the  presence  of  air  the 
colonies  assume  an  orange  colour. 
Staphylococcus  pyogeties  albus  is 
similar  to  staphylococcus  pyogenes 
aureus,  with  the  exception  of  the  colour,  and  is  met  with  in  the 


,•••••«• 


f^ 


<5> 


Fig.  9. — Staphylococcus  pyogenes  aureus 
and  pus  cells. 


Ill 


ACUTE  SUPPURATION— ACUTE   ABSCESS  41 


« 


same    cases.       Its    virulence    is    probably   less,   and    it    is    not  so 
common. 

Streptococcus  pyogenes  is  described  by  some  as  occurring  in  dif- 
ferent forms,  varying  in   their  virulence  and  the  products  of  their 
activity.      These  organisms  set  up  diffuse 
inflammation,   which  spreads   by  the   lym-  ^'.^.••..«         • 

phatics,    whereas    the    staphylococci    more         •••^^••  /     \ 

frequently      cause      circumscribed     acute     »         \ 
abscess.      Streptococci    are    met    with    in       *••••» 
spreading  gangrene,  cellulitis,  septic  infec- 
tion, and  inflammations  of  an  er}'sipelatoid        \    » 
nature.     The  virulence  of  the  organisms  is         \  ••' 

great.  •' 

Streptococcus  erysipelatis  is,  according  to         streptoc!'c?us'pyogenes. 
some,  identical  wiih  the  preceding  strepto- 
coccus ;  but   other   authorities  consider   it   a  distinct  species  (see 
p.  122), 

The  foregoing  are  by  far  the  most  common  organisms  causing 
acute  suppuration ;  but  others,  of  less  virulence  or  of  more  limited 
distribution,  are  met  with. 

Diplococcus  gonorrha'ce  (see  Gonorrhoea,  p.  156). 
Diplococcus ptieu7tioni<2  is  met  with  in  pneumonia,  empyema,  and 
occasionally  in  cerebral  and  other  abscesses. 

Staphylococcus  pyogenes  fa-tidus  is  present  in  abscesses  containing 
putrid  pus,  e.g.  intestinal  or  cerebral,  and  those  in  connection  with 
mucous  membranes. 

Bacillus  coli  cofnmunis  is  constantly  present  in  the  intestine  and 
faeces,  and  is  met  with  in  cases  of  peritonitis  and  suppuration  in  the 
neighbourhood  of  the  intestines. 

Staphylococcus  cereus  albus^  staphylococcus  cereus  Jlavus,  staphylococcus 
pyogenes  citreus,  ?nicrococcus  tenuis^  and  some  others  are  occasionally 
met  with. 

Mode  of  action  of  pyogenic  organisms  —  Formation  of 
abscess. — Pyogenic  organisms  which  have  gained  entrance  into  the 
tissues,  or  have  lodged  in  a  small  capillary,  exert  a  powerful  pepton- 
ising  action  on  the  cells  in  their  neighbourhood,  in  consequence  of 
which  the  parts  undergo  coagulation -necrosis,  and,  losing  their 
structure,  present  a  hyaline,  homogeneous  appearance  (Fig.  1 1,  p.  42). 
Surrounding  this  necrotic  zone,  the  tissues,  irritated  by  the  products 
of  the  organisms — though  in  less  degree — become  acutely  inflam.ed, 
and  are  speedily  infiltrated  by  leucocytes  and  inflammatory  exudation. 
Very  soon  the  leucocytes  invade  the  zone  of  necrosis ;  the  organisms, 


42 


MANUAL   OF   SURGERY 


CHAP. 


freely  multiplying,  pass  into  the  inflamed  area,  kill  the  leucocytes,  and 
prevent  coagulation  of  the  exudate  by  their  peptonising  properties. 
Thus  a  small  abscess  is  formed  (Fig.  ii),  or,  if  the  organism  is 
virulent  enough  or  spreads  by  the  lymphatics,  diffuse  suppuration 
follows.  Limitation  of  the  process — as  in  acute  abscess — is  due  to 
the  fact   that  the  cocci  at  last  meet  with  tissues  whose  resisting 


-        -•'■^\~^.••F■  i,'        . 


!;^4>y.  -- 


i    \w  'i-* : 


V'^'v-^;':^"^:^- 


Fig.  ii. — Section  of  kidney,  showing  in  the  upper  corner  a  mass  of  micrococci,  a  clear  necrotic 
ring,  and  a  Inyer  of  inflammation.  In  the  centre  is  the  further  stage  of  the  process  ;  the 
inflammatorj'  cells  and  the  micrococci  ha%'e  now  infiltrated  the  necrotic  ring,  and  an  abscess 
is  the  result.     (Watson  Cheyne.) 

powers  are  capable  of  checking  their  destructive  properties,  and 
hence  the  pus  is  surrounded  by  a  layer  of  granulations  and  leuco- 
cytes. An  abscess  once  formed  enlarges  through  liquefaction  of  the 
neighbouring  tissues,  by  a  process  similar  to  that  to  which  it  owed 
its  origin.  Certain  tissues,  e.^.  fibrous  tissue  and  blood-vessels  of 
any  size,  resist  the  destructive  action,  and  consequently  purulent 
collections  may  be  subdivided  by  bands  of  undestroye  1  tissue. 

The  wall  of  an  abscess  is  infiltrated  with  coagulated  lymph  and 


in  ACUTE   SUPPURATION— ACUTE  ABSCESS  43 

leucocytes  ;  the  small  vessels  in  the  destroyed  area  are  inflamed, 
thrombosed,  and  subsequently  destroyed  ;  larger  vessels  escape  de- 
struction. Abscesses  spread  in  the  direction  of  least  resistance,  and 
ultimately  burst  at  the  weakest  spot. 

When  the  pus  has  escaped,  the  cavity  of  the  abscess  is  consider- 
ably diminished  by  the  elasticity  and  contraction  of  the  tissues,  and 
ultimately — provided  circumstances  are  favourable  —  is  closed  by 
the  development  of  granulations. 

Pus  is  a  thick,  viscid,  alkaline  fluid  of  a  pale  yellow  colour,  with 
a  sp.  gr.  of  1030.  It  consists  of  80  per  cent  of  water,  the  remainder 
being  albumen,  salts  (chiefly  sodium  chloride),  leucin,  tyrosin,  cho- 
lesterin,  fatty  matter,  and  cellular  debris.  On  standing,  the  pus  cells 
(/>.  dead  leucocytes)  sink  to  the  bottom,  and  the  liquor  puris  {i.e.  non- 
coagulated  fluid  exudate)  forms  a  lighter  top  layer.  Sometimes  it  is 
blood-stained  (sanious  pus),  the  colour  imparted  being  dependent  on 
the  amount  of  blood  and  the  time  it  has  been  shed.  In  cases  of 
suppuration  round  a  blood-clot  the  mixture  is  rusty-coloured,  from 
degenerative  changes  in  the  red  cells.  If  the  corpuscles  are  few  in 
number,  the  fluid  is  thin  and  water)'  ^ichorous  pus),  while  in  other 
cases  the  fatty  matter  and  disintegrated  pus  cells  form  small  masses 
combined  with  fibrinous  material,  giving  the  pus  a  curdy  appearance. 

The  pus  in  abscesses  connected  with  secreting  organs  may  be 
mixed  with  the  normal  secretion ;  thus,  in  liver  abscesses  it  is  of  a 
characteristic  reddish-yellow  or  green  tint,  from  admixture  of  bile. 
After  exposure  to  the  air,  the  colour  of  pus  may  alter  according  to 
the  colour-producing  properties  of  the  organism  present — blue  pus, 
from  the  presence  of  the  bacillus  pyocyaneus,  is  only  met  with  out- 
side the  body. 

Pus  has  normally  a  faint,  sweetish  odour  ;  but  it  may  be  offensive 
from  the  presence  of  putrefactive  organisms.  The  pus  from  some 
cerebral  abscesses,  from  empyemata,  and  from  those  in  connection 
with  mucous  surfaces,  is  intensely  foetid,  from  the  presence  of  the 
staphylococcus  pyogenes  foetidus. 

After  removal  from  the  body,  pus  readily  decomposes,  as  it  will 
do  when  stagnant  in  ill-drained  abscess  cavities.  Decomposition  is, 
however,  impossible  in  unopened  or  unaspirated  abscesses,  since 
})utrefactive  organisms  can  only  gain  admission  from  without 
(p.  94). 

Pus  corpuscles  are  dead  leucocytes,  but  a  few  still  living  may  be 
occasionally  found ;  they  are  rounded  in  shape,  and  coarsely  gran- 
ular, with  a  lobed  or  tripartite  nucleus,  which  is  rendered  clear  by 
the  addition  of  acetic  acid.     Much  granular  detritus  (especially  in 


44  MANUAL   OF   SURGERY  chap. 

chronic  cases)  is  often  present,  owing  to  disintegration  of  the  pus 
cells. 

Many  of  the  pus  cells  contain  organisms  which  are  also  found 
free  in  the  fluid. 

Local  signs  of  acute  abscess. — All  the  signs  of  acute  in- 
flammation are  present  in  a  pronounced  degree,  but  are  somewhat 
altered.  The  pain  is  often  very  severe,  and  of  a  throbbing  character. 
The  sweUing,  on  the  advent  of  suppuration,  rapidly  increases,  provided 
the  distensibility  of  the  part  permits ;  it  is  brawny  and  oedematous 
from  the  presence  of  fluid  exudate  in  the  surrounding  tissues.  The 
presence  of  oedema,  in  cases  of  acute  inflam.mation  where  suppura- 
tion is  likely  to  occur,  is  very  significant  of  the  presence  of  pus,  and 
often  leads  the  surgeon  to  operate  even  in  the  absence  of  fluctua- 
tion. This  is  especially  the  case  in  deep-seated  suppuration.  The 
tense,  brawny  swelling  soon  softens  at  one  spot,  the  softened  area 
being  surrounded  by  a  more  or  less  evident  ring  of  dense  infiltrated 
tissue.  This  area  gradually  increases,  and  the  abscess  approaches 
the  surface,  or  "points,"  and,  if  left  alone,  soon  bursts.  The  skin 
over  an  abscess  is  of  a  dusky  purplish  hue,  but  as  the  pus  comes  to 
the  surface  the  colour  fades,  and  the  skin  becomes  tense,  shiny,  and 
glazed.  Abscesses  in  connection  with  the  gut  are  often  tympanitic, 
from  the  presence  of  gas. 

If  the  fingers  are  placed  over  an  abscess,  and  slight  pressure  is 
made  at  a  point  opposite  with  the  other  hand,  a  wave  is  felt — 
fluctuation.  This  may  be  difficult  or  impossible  of  detection  in 
deep-seated  abscesses,  especially  if  they  are  very  small ;  the  surgeon 
must  then  rely  on  the  other  signs,  notably  the  oedema,  for  his  dia- 
gnosis. It  should  be  remembered  that  fluctuation  ought  never  to  be 
felt  for  in  a  direction  across  the  long  axis  of  muscles,  for  here  a  sen- 
sation very  like  it  can  always  be  obtained.  Abscesses  may  give  rise, 
on  account  of  their  position,  to  special  symptoms,  e.g.  cerebral, 
perineal,  retro-pharyngeal. 

Constitutional  symptoms  of  acute  suppuration. — The 
-  constitutional  symptoms  are  dependent  on  the  absorption  of  toxines 
formed  by  the  organisms,  and  are  merely  an  exaggeration  of  those 
met  wnth  in  acute  inflammations  generally  (see  p.  26).  Suppuration 
is  usually  ushered  in  by  a  feeling  of  chilliness,  sometimes  by  shiver- 
ing fits,  or  even  a  definite  rigor,  especially  if  an  important  organ  is 
the  seat  of  mischief.  The  temperature  rises  and  assumes  a  remit- 
tent type,  showing  a  variation  of  perhaps  3°  or  4°  F.  As  soon  as  the 
abscess  is  evacuated,  the  local  and  general  symptoms  quickly  subside, 
provided  free  drainage  be  ensured  and  putrefaction  prevented  by 


Ill  ACUrii;   SUPPURATION— ACUTE   ABSCESS  45 

antiseptics.     Should  putrefaction  occur,  granulation  and  healing  are 
arrested,  and  the  patient  is  exposed  to  the  risk  of  septic  absorption. 

Diagnosis  of  acute  abscess. — This  is  usually  readily  made, 
but  it  has  occasionally  haj)pcnLd  that  an  inflamed  aneurism  has 
been  mistaken  for  abscess.  A  knowledge  of  the  history,  and  a 
careful  examination  of  the  case,  will  usually  be  sufficient  to  avoid 
error  (see  chap.  ii.  vol.  iii.). 

Treatment  of  acute  abscess. — As  soon  as  suppuration 
has  occurred,  no  time  should  be  lost  in  giving  free  exit  to  the 
pus.  Delay  in  opening  an  abscess  is  not  only  useless,  but  may 
be  dangerous,  as  it  may  burst  into  some  cavity  or  hollow  viscus, 
thereby  entailing  the  most  serious  consequences;  moreover,  in  all 
cases  the  abscess  goes  on  increasing  in  size  until  it  has  been 
evacuated.  The  incision  should  be  long  enough  to  ensure  free 
drainage,  and  should  be  so  placed  that  it  is  opposite  the  most 
dependent  part  of  the  abscess,  provided  the  anatomy  of  the  parts 
will  permit.  In  planning  the  incision,  it  must  be  borne  in  mind 
that  asepticity  is  of  paramount  importance,  and  the  opening 
should  be  made  in  such  a  position,  when  possible,  as  to  ensure  the 
least  risk  of  contamination  from  without.  When  an  abscess  has 
been  incised,  its  cavity  should  be  explored  by  the  finger,  and  any 
fibrous  septa  which  may  be  found  subdividing  it  should,  if  neces- 
sary, be  broken  down,  so  that  there  may  be  no  "  pocketing  "  of  dis- 
charge ;  the  presence  of  loculi  may  necessitate  the  establishment  of 
counter-openings.  As  a  rule,  an  abscess  cavity  does  not  require 
washing  out,  but  if  the  pus  is  foetid,  e.^.  in  abscesses  in  connection 
with  the  gut,  gentle  syringing  with  an  unirritating  antiseptic  lotion 
should  be  employed  for  a  few  days,  until  the  discharge  becomes 
sweet.  For  this  purpose,  one  drachm  of  tincture  of  iodine  to  the 
pint  of  warm  water,  or  four  grains  of  boric  acid  to  the  ounce,  are 
the  best  solutions ;  sterilised  water  may  also  be  used.  A  small 
quantity  of  iodoform  emulsion,  injected  into  and  allowed  to 
remain  in  the  cavity,  is  a  powerful  deodoriser.  Solutions  of 
mercury  or  carbolic  acid  should  be  avoided  in  the  case  of  large 
abscesses,  or,  if  used,  must  be  very  weak,  for  they  may  be 
absorbed  by  the  granulations  and  give  rise  to  toxic  symptoms. 
The  cavity  of  an  abscess  must  be  efficiently  drained  by  a  good- 
sized  tube,  introduced — if  necessary  by  a  pair  of  sinus  forceps — 
to  within  about  an  inch  of  its  deepest  part ;  the  calibre  of  the  tube 
must  be  of  good  size,  to  allow  the  fluid  to  escape.  As  healing 
takes  place  the  tube  will  be  gradually  pushed  out  of  the  wound, 
and  must  be  shortened  from  time  to  time,  but  should  not  be  dis- 


46  MANUAL   OF   SURGERY  chap. 

pensed  with  until  the  wound  is  quite  superficial.  If  the  opening 
be  large,  a  flanged  tube  is  the  best,  as  its  shape  prevents  it  from 
sHpping  into  the  cavity;  in  other  cases  the  tube  may  be  retained 
in  position  by  threads  of  silk  or  by  a  safety-pin  so  placed  that  it 
Ues  across  the  long  axis  of  the  incision. 

All  abscesses  must  be  dressed  antiseptically,  according  to  the 
method  described  in  chapter  i.  vol.  ii.  The  dressing  must  be 
changed  frequently  if  there  is  much  discharge,  but  as  healing  pro- 
gresses it  may  be  left  undisturbed  for  a  longer  time ;  at  first  most 
abscesses  require  dressing  once  in  every  twenty-four  hours,  large 
ones  more  frequently.  Should  the  discharge  soak  through  the 
dressing,  this  must  be  immediately  changed  or  packed.  When  an 
abscess  has  been  opened  and  there  is  much  surrounding  inflamma- 
tion, it  may  be  advisable  to  foment  the  parts ;  boracic  fomentations 
are  the  safest,  and  should  always  be  employed  on  account  of  their 
antiseptic  properties.  Poultices,  not  being  antiseptic,  should  in  all 
cases  be  avoided. 

Methods  of  opening*  abscesses. — The  most  suitable  situation 
for  the  incision  having  been  determined,  it  may  be  made  by  cutting 
from  without  inwards,  or  by  transfixion  with  a  bistoury  or  Syme's 
knife.  The  latter  method  has  the  advantage  of  rapidity  and  does 
not  cause  so  much  pain,  but  it  should  never  be  employed  in  parts 
where  important  structures  may  be  damaged.  Deep  -  seated 
abscesses,  or  those  situated  in  dangerous  regions,  should  be  opened 
by  Hilton's  method.  A  small  incision  is  made  through  the  super- 
ficial structures,  and  the  cavity  is  then  reached  by  insinuating  a 
pair  of  sinus  forceps  through  the  deeper  tissues;  as  soon  as  the 
abscess  has  been  reached,  pus  escapes  by  the  side  of  the  forceps, 
whose  onward  progress  is  no  longer  resisted ;  the  forceps  are  then 
opened  and  withdrawn,  and  the  wound,  being  stretched  apart,  may 
subsequently  be  enlarged  by  the  fingers  or  by  incision  with  a  blunt- 
pointed  bistoury. 

Acute  abscesses  of  an  infective  nature,  e.g.  bubo,  should  be 
carefully  and  thoroughly  sharp -spooned  when  they  have  been 
opened ;  by  this  means  sloughy  tissues  are  removed,  and  the  cavity, 
freed  of  irritating  material,  heals  much  more  quickly. 

Acute  diffuse  suppuration. — See  Cellulitis,  p.  127. 


CHRONIC    ABSCESS 


Chronic  abscesses  differ  materially  from  acute  in  their  etiology, 
course,  signs,  dangers,  and  treatment. 


Ill  CHRONIC    ABSCKSS  47 

Etiology. — The  ordinary  pyogenic  organisms  arc  but  rarely 
found  in  chronic  suppurative  j)rocesses,  which  in  the  vast  majority 
of  cases  are  due  to  the  htjuefaction  and  disintegration  of  tubercular 
deposits.  The  first  step  in  the  process  is  the  infiltration  of  the 
tissues  by  tuberculous  material  which  forms  a  hard,  dense  mass; 
the  cells  undergo  caseation,  and  the  broken-down  ones,  mixed 
with  fluid,  form  the  curdy,  watery  pus  so  characteristic  of  chronic 
suppuration.  By  a  gradual  breaking  down  of  the  abscess  wall  and 
surrounding  tissues,  or  by  the  coalescence  of  neighbouring  foci  of 
suppuration,  the  abscess  increases  in  size.  Syphilis  is  also  a  cause 
of  chronic  suppuration. 

When,  as  sometimes  happens,  a  chronic  abscess  suddenly 
assumes  subacute  or  acute  characters,  the  ordinary  pyogenic  organ- 
isms may  be  found  in  the  pus.  Acute  abscesses  may,  if  the 
organisms  perish,  become  chronic. 

Anatomy  and  course. — The  progress  of  a  chronic  abscess  is 
very  slow,  and  may  extend  over  a  period  of  many  months  before  the 
patient's  attention  is  directed  to  it.  Chronic  abscess  is  comn.only 
met  with  in  diseases  of  bones  or  joints,  in  the  lymphatic  glands  and 
subcutaneous  tissue,  and  in  organs  which  are  the  seat  of  tubercle. 
Extension  takes  place  along  the  lines  of  least  resistance,  e.g.  along 
connective  tissue  planes,  under  the  sheaths  of  muscles,  or  along 
arterial  tracks.  Large  abscesses  which  have  burrowed  far  may 
present  numerous  cavities  connected  together  by  narrow  tracks 
at  the  points  of  greatest  resistance ;  thus,  when  a  psoas  abscess 
passes  beneath  Poupart's  ligament  it  is  contracted,  widening  again 
in  the  thigh.  Owing  to  the  chronicity  of  the  process,  the  abscess 
wall  is  usually  of  considerable  thickness  through  induration  of  the 
soft  structures,  so  that  it  may  have  a  distinctly  cystic  character, 
thus  enabling  the  surgeon  to  dissect  it  cleanly  out — a  most 
important  point,  since  the  wall  is  infiltrated  with  tuberculous  matter 
which,  unless  removed,  will  perpetuate  the  mischief.  The  density 
of  the  wall  may  be  so  great  that  the  abscess  simulates  a  solid 
tumour. 

The  walls  of  chronic  tubercular  abscesses  are  infiltrated  with 
tubercle  bacilli  and  nodules,  the  inflammatory  induration  gradually 
diminishing  as  more  healthy  parts  are  reached.  Unhealthy  granula- 
tions line  the  interior,  and  masses  of  coagulated  exudate  and  cells 
may  form  a  more  or  less  definite  lining — the  so-called  pyogenic 
membrane  of  former  times. 

Arterial  trunks  in  the  neighbourhood  of  chronic  abscesses  gener- 
ally escape  destruction  ;  but  they  may  be  denuded  and  stretch  across 


48  MANUAL  OF  SURGERY  chap. 

the  cavity  as  rounded  cords,  and  care  must  be  taken  not  to  mistake 
them  for  fibrous  septa.  In  pulmonary  cavities  this  condition  is 
frequently  seen  and  is  one  of  danger,  since  the  artery,  deprived  of  its 
natural  support,  may  become  dilated  or  aneurismal.  The  bursting 
of  such  an  aneurism  is  the  commonest  cause  of  fatal  haemoptysis. 

Occasionally  the  pus  is  like  that  met  with  in  acute  abscess,  but 
in  the  majority  of  cases  it  is  thin  and  watery,  and  contains  masses 
of  broken-down  cells  and  lymph  which  give  it  a  curdy  appearance. 
In  tubercular  cases  the  discharge  is  infective,  though  tubercle 
bacilli  are  not  often  found,  as  they  have  undergone  disintegration, 
and  only  the  spores  remain ;  if,  however,  it  be  injected  into  guinea- 
pigs  or  other  susceptible  animals,  general  tuberculosis  results. 

Sooner  or  later  most  chronic  abscesses  point  and  burst,  but  this 
may  not  occur  for  many  months  or  at  all.  In  the  latter  case  the 
fluid  parts  of  the  pus  are  absorbed  and  the  caseous  detritus  remains 
encapsuled,  a  permanent  cure  perhaps  resulting ;  or  else  the  caseous 
patch  may,  even  after  many  years,  again  become  purulent  through 
slight  irritation  (Residual  Abscess).  Lastly,  the  caseous  mass  may 
become  infiltrated  with  lime  salts,  and  the  whole  shrink  and  be  in- 
vested with  a  fibrous  capsule ;  when  this  has  occurred  the  calcified 
mass  is  practically  a  foreign  body,  and  may  remain  quiescent,  or, 
acting  as  an  irritant  to  the  tissues,  may  be  a  factor  in  determining 
future  suppuration  in  its  neighbourhood  under  other  favouring 
circumstances. 

Dangers  and  complications. — Apart  from  the  dangers  and 
complications  which  may  occur  from  the  presence  of  a  tubercular 
focus  in  the  body,  and  those  which  are  inseparable  from  collec- 
tions of  purulent  material  in  important  regions,  a  chronic  abscess, 
when  opened,  exposes  the  patient  to  the  risks  attending  putre- 
factive decomposition  of  the  discharges,  which  is  especially  liable 
to  occur  if  the  abscess  cannot  be  efficiently  drained  or  asepticity 
ensured  (Chronic  Septic  Intoxication,  p.  io8),  Moreover, 
when  a  chronic  abscess  has  been  opened  and  drained,  the 
constant  discharge  will  exhaust  and  undermine  the  health  of  the 
patient,  and  may  lead  to  albuminoid  and  fatty  changes  in  the 
viscera.  It  is  of  paramount  importance  that  the  possibility  of 
these  dangers  should  be  borne  in  mind  when  determining  on  the 
best  course  of  treatment  to  pursue  in  any  given  case.  Lender 
ordinary  conditions  and  proper  treatment  cure  may  usually  be 
brought  about,  but  there  are  unfortunately  a  certain  percentage  of 
cases  in  which  the  primary  mischief  (e.g.  spinal  caries)  continues  to 
advance  in  spite  of  all  our  skill  and  attention,  and  the  discharge 


Ill  CHRONIC   ABSCESS  49 

persists  as  copiously  as  at  first,  the  patient  ultimately  sinking  from 
exhaustion  too  often  complicated  by  septic  absorption. 

Signs  and  symptoms. — A  chronic  abscess  may  exist  for  a  long 
time  without  showing  evidence  of  its  presence,  enlarging  so  slowly 
that  the  parts  adapt  themselves  to  the  swelling.  It  is  common  ex- 
perience that  in  cases  of  spinal  caries  with  psoas  abscess  the 
symptoms  may  be  all  referred  to  the  diseased  vertebrae,  the  patient 
being  quite  unaware  of  the  existence  of  even  a  large  abscess. 

The  local  signs  of  acute  inflammation  are  absent,  although  there 
may  be  a  little  redness  and  oedema  of  the  skin  over  the  abscess. 
Pain  may  or  may  not  be  present.  In  large  abscesses  distinct 
fluctuation  can  be  obtained,  but  in  deep-seated  and  small  ones  this 
may  be  quite  absent,  the  thickness  of  the  walls  imparting  to  the 
swelling  the  characters  of  a  solid  growth,  of  which  the  density  varies 
from  elasticity  to  almost  stony  hardness.  ^Nlany  cases  of  chronic 
breast  abscess  have  only  been  diagnosed  after  amputation  of  the 
organ  for  supposed  cancer.  Chronic  abscesses  may,  by  the  pressure 
they  induce,  lead  to  special  symptoms  in  different  regions  of  the 
body,  just  as  would  be  the  case  from  a  solid  growth. 

Constitutional  disturbance  is  absent  so  long  as  the  abscess  is 
unopened,  and  even  after  this  provided  no  putrefaction  occurs. 
Sometimes  there  is  a  slight  rise  of  temperature  at  night,  and  this, 
coupled  with  other  indications,  is  of  great  diagnostic  value. 

Diagnosis. — The  diagnosis  of  chronic  abscess  is  by  no  means 
always  easy,  it  being  often  confounded  with  a  solid  or  cystic  tumour. 
The  chief  points  to  rely  upon  in  arriving  at  a  diagnosis  are  the 
presence  of  fluctuation,  oedema  of  the  overlying  tissues,  want  of 
complete  circumscription  of  the  tumour,  and  the  presence  of  some 
source  of  irritation,  e.g.  diseased  bone ;  should  there  be  a  nocturnal 
rise  of  temperature  in  conjunction  with  the  other  signs,  the  diagnosis 
of  chronic  abscess  is  usually  certain.  Solid  and  cystic  tumours  are 
usually  more  clearly  locaHsed  and  have  a  well-defined  margin, 
whereas  the  indurated  tissue  surrounding  a  chronic  collection  of 
pus  fades  away  gradually  as  healthy  parts  are  approached.  In 
cases  where  an  absolute  diagnosis  cannot  be  made,  the  tumour  may 
be  explored  with  a  fine  syringe  or  aspirator,  or  by  means  of  an 
incision ;  the  latter  course  should  always  be  adopted  in  doubtful 
tumours  of  the  breast  before  resorting  to  amputation. 

Treatment. — The  treatment  of  chronic  abscess  depends  in  great 
measure  on  its  origin  and  seat,  and  in  considering  diseases  of  special 
organs  and  tissues  the  methods  to  be  adopted  will  be  indicated. 

Simply  emptying  an  abscess  by  aspiration  is  merely  a  temporary 

VOL.  I  E 


5o  MANUAL   OF   SURGERY  chap. 

means  to  relieve  tension ;  the  pus  rapidly  reaccumulates  and  cure 
cannot  be  hoped  for.  The  persistence  of  chronic  abscess  is  usually 
dependent  on  a  tubercular  condition  of  its  walls,  and  so  long  as 
this  state  remains,  no  useful  end  is  gained  by  drawing  off  the 
purulent  collection. 

Aspiration  with  the  injection  of  iodoform  emulsion  offers  a  better 
chance  of  success  than  does  aspiration  alone.  The  iodoform  exerts 
a  beneficial  action  on  the  abscess  wall,  and  may  arrest  the  morbid 
process  and  bring  about  a  more  healthy  state.  Sometimes  one 
injection  suffices  for  cure ;  more  often  the  fluid  reaccumulates, 
though  in  less  quantity,  and  the  operation  must  be  repeated.  It 
may  completely  fail,  and  should  not  be  relied  on  except  in  cases 
unsuitable  for  one  of  the  foliowing  methods. 

Subcutaneous  and  glandular  abscesses  may  be  dissected  out 
entire,  like  a  simple  cystic  tumour.  The  wall  should  be  completely 
removed  and  the  wound  closed,  union  by  first  intention  resulting  in 
most  cases.  This  is  the  ideal  treatment  of  chronic  abscess,  and 
should  be  adopted  wherever  practicable ;  the  patient  is  completely 
freed  of  his  disease  and  a  healthy  wound  left. 

Some  subcutaneous  and  glandular  abscesses  may  not,  on  account 
of  their  position  and  connections,  be  capable  of  complete  removal 
by  excision.  In  such  cases  the  sac  should  be  freely  incised,  the  pus 
evacuated,  and  the  entire  wall  dissected  away  with  the  knife  or 
snipped  away  with  scissors.  If  any  doubt  remains  as  to  the  com- 
plete removal  of  all  the  diseased  tissue,  the  cavity  should  be  well 
sharp-spooned  and  treated  with  chloride  of  zinc  (40  grs.  ad  ^i.)  or 
iodoform  emulsion.  The  wound  may  now  be  closed  and  union  by 
first  intention  will  usually  occur.  Sometimes  the  cavity  fills  again 
and  the  operation  has  to  be  repeated.  In  cases  where,  even  after 
dissection  and  scraping,  it  is  probable  that  some  of  the  diseased 
tissue  still  remains,  no  attempt  should  be  made  to  close  the  wound ; 
it  should  be  well  iodoformed  and  packed  with  strips  of  antiseptic 
giuze.  These  may,  under  ordinary  circumstances,  remain  untouched 
for  three  or  four  days ;  on  their  removal  the  interior  of  the  abscess 
will  be  found  covered  with  healthy  granulations,  but  should  any  part 
still  show  evidence  of  disease,  it  will  require  sharp-spooning  again. 

In  cases  unsuited  for  treatment  by  the  above  means,  e.g.  spinal 
abscesses,  a  small  incision  should  be  made  at  the  most  suitable  spot 
and  the  pus  evacuated.  The  wall  of  the  abscess  is  then  freely 
sharp-spooned  with  a  flushing  gouge,  the  detritus  being  washed 
away  by  sterilised  water  or  weak  boric  acid  solution.  The  scraping 
should  be  complete  and  continued  until   no   more  detritus  couieo 


Ill  SINUS   AND    FISTULA  51 

away,  due  care  being  taken  not  to  perforate  the  abscess  wall.  The 
cavity  should  now  be  coni[)letely  en4)tied  and  dried  with  rough 
sponges,  so  as  to  remove  all  debris.  I()dor(jrni  emulsion  is  applied 
to  all  parts  of  the  wall,  and  a  lilUc  K  ft  in  the  cavity.  The  wound 
is  carefully  closed  and  dressed,  the  dressings  remaining  undisturbed 
until  union  is  complete.  A  drainage  tube  should  usually  be 
employed  for  a  couple  of  days  to  remove  the  serous  fluid  which  will 
be  poured  out.  This  treatment  may  at  once  bring  about  a  cure, 
but  in  some  cases  the  abscess  fills  again,  the  fluid  being  more 
watery  and  not  so  abundant.  Under  such  circumstances  the 
operation  must  be  repeated,  and  this  done  a  third  or  even  a  fourth 
time  if  necessary.  In  successful  cases  the  cavity  is  obliterated  and 
the  abscess  is  represented  by  a  fibrous  mass,  often  with  a  casieous 
centre.  Sometimes  failure  results,  the  wound  breaking  down  and 
the  pus  escaping  externally ;  cure  may  even  then  be  brought  about 
by  a  repetition  of  the  process,  the  edges  of  the  wound  being  freely 
sharp-spooned  and  then  carefully  approximated. 

If  in  spite  of  every  care  a  chronic  abscess  cannot  be  made  to 
heal  but  threatens  to  burst,  the  surgeon  is  compelled  to  lay  it  open 
and  drain  it.  The  incision  must  be  large  enough  to  ensure  perfect 
drainage,  and  be  so  placed  that  the  risk  of  putrefaction  is  reduced 
to  a  minimum. 

If  a  chronic  abscess  is  dependent  upon  disease  of  a  bone  or  any 
similar  condition,  that  disease  must  itself  receive  appropriate  treat- 
ment ;  thus,  sequestra  must  be  removed  and  carious  cavities  sciaped. 

The  importance  of  strict  asepsis  in  chronic  abscess  is  paramount. 
If  putrefactive  organisms  gain  admission,  they  not  only  give  rise  to 
toxines  which,  being  absorbed,  produce  septic  intoxication,  but  by 
their  local  action  they  impart  a  fresh  impetus  to  the  disease.  No 
one  is  justified  in  opening  a  chronic  abscess  unless  he  is  perfectly 
familiar  with  the  details  of  antiseptic  surgery,  and  can  ensure  perfect 
asepticity. 

The  constitutional  treatment  is  directed  chiefly  to  building  up 
the  patient's  health,  (iood  food,  tonics,  malt  liquor  and  stimulants 
if  necessary,  with  plenty  of  fresh  air,  are  essential. 


Sinus  and  Fistula 

SINUS 

When  an  abscess  has  been  opened  or  has  burst,  it  may  not  com- 
pletely heal,  a  narrow  suppurating  canal  or  sinus  persisting. 


52  MANUAL  OF   SURCxERY  chap. 

Anatomy  of  sinuses. — A  sinus  is  a  narrow  channel,  often  of 
-great  length,  sometimes  straight,  but  more  usually  sinuous,  opening 
externally  by  a  narrow  mouth ;  the  deeper  portion  may,  on  account 
of  insufficient  outlet,  be  dilated  by  retained  discharge  into  a  small 
abscess  cavity  (Fig.  12,  C,  p.  54).  The  walls  in  old-standing  cases 
are  tough  and  indurated  :  the  inner  surface  varies  in  appearance 
according  to  the  age  of  the  sinus.  When  recent,  the  granulations 
are  numerous,  though  pale,  flabby,  and  unhealthy ;  they  bleed 
readily  on  probing,  and  are  highly  sensitive ;  in  chronic  cases 
the  inner  surface  may  be  smooth  and  almost  devoid  of  granu- 
lations, and  probing  does  not  cause  pain  or  bleeding  unless 
roughly  performed.  Sinuses  may  be  multiple,  as  in  cases  of 
diseased  bone. 

The  external  opening  of  a  sinus  is  usually  its  narrowest  part,  and 
is  often — especially  in  sinuses  of  recent  formation,  and  those  due 
to  bone  disease — surrounded  by  exuberant,  unhealthy  granulations. 
The  purulent  discharge  is  unhealthy  and  watery  in  nature,  and  may 
contain  lime  salts  if  the  sinus  leads  to  diseased  bone.  In  some 
cases  the  discharge  is  copious,  in  others  scanty ;  in  all  it  is  likely  to 
be  fcetid  from  decomposition.  The  mouth  of  a  sinus  may  be  so 
narrow  that  it  becomes  temporarily  occluded  either  by  congestion 
or  by  the  formation  of  a  scab,  the  pus,  accumulating  behind,  gives 
rise  to  symptoms  of  abscess  formation  ;  but  when  tension  is  high 
enough  it  escapes,  only  to  re-collect. 

Causes  of  sinus. — An  abscess  may  remain  unhealed  from 
one  or  more  of  the  following  causes,  but  is  much  more  likely  to  re- 
sult in  the  case  of  chronic  abscess  (so  often  dependent  on  tubercle) 
than  in  that  of  acute  : — 

(i)  The  opening  is  too  small,  or  not  in  the  most  favourable 
situation,  so  that  the  discharge  does  not  have  free  exit. 

(2)  Putrefaction  of  the  discharge. 

(3)  The  presence  of  a  foreign  body,  e.g.  sequestrum. 

(4)  Want  of  rest  owing  to  its  situation  among  muscles. 

(5)  Its  specific   nature,  e.g.  tubercle;  the  virus  being  present  in 

the  granulations  and  in   the   wall  of  the  sinus,   does  not 
allow  healing  to  occur. 

(6)  General  ill-health  of  the  patient. 

Diagnosis. — The  diagnosis  of  the  existence  of  a  sinus  is  usually 
simple,  but  sometimes  the  opening  is  so  small  and  so  well  concealed 
among  folds  of  tissue,  e.g.  round  the  anus,  that  careful  search  is 
necessary.  The  chief  point  is  to  determine  the  course  and  origin 
of  the  suppurating  track.      It   m.ust  be  remembered   that  abscesses 


Ill  SINUS  53 

travel  in  the  direction  of  least  resistance,  and  that  their  point  of 
bursting  by  no  means  necessarily  corresponds  to  that  of  their  origin, 
e.g.  spinal  abscesses.  The  history  of  the  case  often  affords  much 
information,  but  chief  reliance  must  be  placed  on  careful  and  gentle 
probing ;  gentleness  is  necessary,  not  only  to  lessen  pain,  but  to 
avoid  pushing  the  probe  through  the  wall  of  the  sinus  into  the 
surrounding  tissues,  and  so  being  misled. 

The  appearance  of  a  sinus  is  sometimes  suggestive  of  its  origin ; 
thus,  in  the  case  of  caries,  the  mouth  of  the  sinus  is  swollen  and 
filled  with  pale  unhealthy  granulations,  while  in  necrosis  the  latter 
are  absent  and  the  mouth  is  depressed.  The  situation  is  sometimes 
useful  in  determining  the  seat  of  original  mischief;  for  instance, 
in  hip  disease  originating  in  the  acetabulum  the  sinuses  are  usually 
present  about  the  pubic  and  gluteal  regions  and  Poupart's  ligament ; 
but  when  the  synovial  membrane  or  head  of  the  femur  is  the  primary 
seat  of  the  mischief,  the  sinuses  open  in  the  vicinity  of  the  great 
trochanter. 

Treatment. — A  knowledge  of  the  causes  leading  to  the  estab- 
lishment of  a  sinus  indicates  the  steps  necessar)'  for  effecting  a 
cure. 

An  inefficient  opening  must  be  enlarged  so  that  free  drainage  is 
ensured,  and  one  or  more  counter-openings  may  be  necessary.  Any 
foreign  body,  such  as  a  sequestrum,  must  be  removed.  If  the 
interior  of  the  sinus  is  unhealthy,  either  by  reason  of  neglect,  putre- 
faction, or  the  specific  nature  of  the  mischief  {e.g.  tubercle),  the 
sinus  should  be  freely  laid  open  and  "sharp -spooned,"  or  the 
wall  dissected  out,  and  the  wound  having  been  rendered  aseptic, 
should  be  allowed  to  granulate  from  the  bottom.  If  a  sinus  can  be 
completely  dissected  out,  the  wound  may  be  sutured  and  healing  by 
first  intention  secured.  Sometimes  the  position  of  a  sinus  among 
important  structures  does  not  admit  of  such  radical  treatment,  nnd 
the  surgeon  must  be  content  with  enlarging  the  orifice  and  attempt- 
ing to  induce  healthy  action  by  means  of  stimulating  and  aseptic 
lotions,  such  as  red  wash  (zinc  sulph.  grs.  2,  tr.  lavander  TTl^  10,  aq. 
ad  51.)  or  chloride  of  zinc,  gr.  i  to  51.  distilled  water.  A  probe, 
warmed  and  coated  with  nitrate  of  silver,  and  passed  down  the 
sinus,  occasionally  induces  healing. 

If  movement  of  neighbouring  muscles  keeps  up  constant  irrita- 
tion, this  must  be  counteracted  by  rest,  position,  and  such  other 
means  as  seem  appropriate  to  the  case.  If  the  general  health  is 
feeble,  good  food,  tonics,  and  country  air  are  the  chief  indica- 
tions. 


54  MANUAL  OF  SURGERY  chap. 

FISTULA 

A  fistula  is  practically  a  sinus  opening  into  some  cavity  or  hollow 
viscus  and  on  to  the  surface  of  the  skin  (Fig.  12,  A).  Fistulous 
openings,  without  any  external  orifice  (Fig.  12,  B),  may  also  exist 
between  cavities  or  tubes,  e.g.  vesico-vaginal  fistula. 

Anatomy  of  fistula. — Fistulae  usually  present  similar  charac- 
ters to  those  described  under  sinus.     They  may  be  single  or  multiple, 

and  vary  considerably  in  length  and  in 
the  course  they  take,  so  that  the  external 
opening  by  no  means  necessarily  corre- 
sponds with  the  seat  of  the  original  mis- 
chief? A  fistulous  track  may  not  open 
directly  into  the  cavity  with  which  it 
communicates,  but  may  burrow  along  the 
soft  structures.  This  is  well  seen  in 
some  cases  of  faecal  fistula  resulting  from 
gangrene  of  a  strangulated  hernia. 
Fig.  12.— Diagram  of  the  common  Oldfistulouscommunications  betwccn 

lorms    01    nstulae  in  ano.      R, 

rectum;  A,  complete  fistula,     two  mucous  surfaccs,  e.g.  vcsico-vagiual, 

dilated  in  the  middle ;  B,  blind  i  •  i  c    ^^ 

internal    fistula;    C,   blind    ex-       Hiay    nOt    ShOW    evldcnCC    Ot    the    CaUSC    tO 

ternai  fistula,  the  sinus  du-id-     ^^-)^\(^\^    they    owe    their    formation,    the 

ing  at  tne  upper  end.     (roUin.)  .  ^  '       . 

margins  of  mucous  membrane  being 
soundly  healed,  and  the  track  itself  lined  with  epithelium. 

Causes  of  fistula. — A  fistula  may  result  from  suppuration, 
the  abscess  bursting  externally  and  into  some  cavity,  or  from  injury 
which  either  at  once  establishes  the  communication  or,  at  a  later 
date,  causes  it  through  sloughing.  Fistulas  are  not  infrequently 
formed  as  the  result  of  invasion  by  and  breaking  down  of  a  malig- 
nant growth,  e.g.  entero-vesical.  Fistulous  openings  are  sometimes 
made  by  the  surgeon  for  the  rehef  of  strictures  and  other  conditions, 
e.g.  tracheotomy,  colotomy.  Lastly,  fistulae  may  be  due  to  some 
congenital  defect,  e.g.  branchial  fistulae. 

In  whatever  way  a  fistula  is  formed,  it  is  kept  open  by  the 
passage  along  it  of  the  contents  of  the  tube  with  which  it  communi- 
cates, and  the  question  as  to  whether  it  will  heal  or  not  depends  in 
great  measure  upon  the  permeability  of  the  canal  into  which  it 
opens.  Thus,  perineal  fistulae  occurring  as  the  result  of  stricture  of 
the  urethra  will  not  heal  unless  the  stricture  be  treated,  whereas  a 
similar  fistula  intentionally  made  for  the  purpose  of  exploring  the 
bladder  heals  readily  under  ordinary  circumstances. 

Diagnosis  of  fistula. — When  a  fistula  has  a  direct  opening  on 


Ill  FISTULA  55 

the  surface,  the  character  of  the  discharge  is  sufficient  evidence  of 
the  nature  of  the  case ;  thus,  urine  escapes  through  perineal,  faeces 
through  intestinal  fistulae. 

If  there  is  no  external  opening  the  diagnosis  is  more  difficult. 
Thus,  a  fistula  opening  into  the  rectum,  but  not  externally,  must  be 
sought  for  by  the  speculum ;  while  an  entero-vesical  fistula  may  De 
diagnosed  by  the  presence  in  the  urine  of  undigested  particles  of 
food,  and  sometimes  by  the  passage  of  flatus /fr  iireihram. 

Treatment. — If  a  fistula  communicates  with  a  tube,  the  lumen 
of  which  is  contracted,  the  stricture  must  first  be  dilated  or  cut. 
As  soon  as  there  is  a  free  passage  along  the  canal,  the  fistula  will, 
if  of  recent  formation,  usually  heal  soundly  and  quickly,  provided 
it  is  kept  clean.  Healing  may  be  hastened  by  the  passage  of  a  hot 
wire  alojig  the  track  of  the  fistula,  or  it  may  be  laid  open  and  allowed 
to  heal  from  the  bottom,  as  in  fistula  /;/  ano. 

If  a  fistula  remains  unhealed,  and  if  it  be  due  to  sloughing  of 
the  soft  parts,  its  treatment  depends  chiefly  on  the  size  of  the  arti- 
ficial communication,  and  on  the  state  of  the  walls.  Small  openings 
may  be  made  to  close  by  introducing  a  fine  cauter}'  point  as  already 
stated ;  but  large  ones  require  some  form  of  plastic  operation  suit- 
able to  the  case.  No  such  operation  should,  however,  be  undertaken 
until  all  inflammation  has  been  arrested  for  some  time. 

Fistulae  due  to  the  invasion  of  cancerous  or  sacromatous  growths 
need  no  treatment  beyond  the  obser^'ance  of  cleanliness.  Con- 
genital fistulas,  if  amenable  to  treatment,  must  be  dissected  out, 
since  the  walls  are  lined  with  epithelium  which,  unless  removed, 
efiectually  prevents  closure. 


CHAPTER    IV 

Ulceration  and  Ulcers 

Inflammation  causing  death  of  the  skin  or  of  a  mucous  surface 
gives  rise  to  ulceration.  If  portions  of  tissue,  large  or  small,  die  en 
fnasse^  they  are  called  "sloughs,"  and  the  process  is  known  as 
"sloughing,"  and  stands,  as  it  were,  in  mid-position  between  ulcera- 
tion and  gangrene.  When  ulceration  is  the  outcome  of  inflammation 
of  a  non-specific  character,  it  is  said  to  be  simple.  Specific  ulcers 
are  those  dependent  on  the  action  of  a  specific  virus,  e.g.  soft  chancre, 
tubercle,  syphilis.  Cancerous  or  sarcomatous  tumours  may  invade 
and  destroy  superficial  structures,  and  an  open  wound,  or  so-called 
malignant  ulcer,  results ;  the  term  ulceration  cannot  properly  be 
applied  to  such  cases. 

SIMPLE    OR    NON-SPECIFIC    ULCERATION 

Etiology. — The  predisposing  causes  of  ulceration  are  those 
local  or  general  states  which,  by  diminishing  the  resisting  power  of 
the  tissues,  favour  their  death  as  a  result  of  inflammation.  A 
knowledge  of  these  causes  is  of  primary  importance,  not  only  in  the 
prevention,  but  in  the  cure  of  ulceration.  Among  the  general  causes 
— all  of  which  act  by  lowering  vitality — may  be  mentioned  old  age, 
insufificient  and  improper  food,  bad  hygiene,  chronic  alcoholism,  and 
certain  constitutional  dyscrasis,  such  as  gout,  scurvy,  diabetes, 
syphilis,  and  tubercle ;  and  not  only  do  these  diseases  favour  the 
occurrence  of  simple  ulceration,  but  the  formation  of  ulcers  of  de- 
finite clinical  characters  is  a  manifestation  of  the  diseases  themselves. 

Local  causes  act  by  interfering  with  the  due  nutrition  of  the  part, 
thus  rendering  it  very  intolerant  of  even  slight  irritation.  The  most 
potent  of  these  is  certainly  chronic  congestion  from  impeded  venous 


CH.  IV     SIMPLE   OR   NON-SPECIFIC   ULCERATION         57 


return.  A  striking  example  of  this  is  to  be  seen  in  ulceration  of  the 
leg  as  the  result  of  varicose  veins,  especially  in  those  who  stand  for 
many  hours  during  the  day  (Fig.  13).  In  the  presence  of  venous 
congestion,  the  slightest  scratch  may 
be  sufficient  to  determine  the  com- 
mencement of  ulceration  -which  may 
persist  for  years.  Thrombosis  of 
the  veins  leads  to  a  like  result 
After  phlegmasia  dolens,  ulceration 
of  the  legs  is  by  no  means  un- 
common ;  and  so  long  as  the  circu- 
lation is  imperfect,  the  ulcers  prove 
very  refractory  to  treatment,  break- 
ing down  again  and  again  on  the 
slightest  provocation.  Deficient 
arterial  supply  through  disease  of,  or 
pressure  on  the  vessels,  defective 
innervation  of  the  tissues,  pressure, 
or  continued  mechanical  or  chemi- 
cal irritation,  may  all  induce  ulcera- 
tion. Previously  inflamed  parts  and 
cicatrices,  of  which  the  vascular 
supply  is  poor,  are  liable  to  ulcerate 
from  slight  causes. 

The  detepmining  causes  are 
practically  identical  with  those  of 
inflammation,  acting  with  slight  in- 
tensity, and  for  a  considerable  time. 
Mechanical  irritation,  e.g.  vesical  calculus  or  badly  fitting  surgical 
appliances,  may  induce  ulceration  or  sloughing,  according  to  the 
degree  of  damage  inflicted.  Chemical  irritants,  ev6n  of  feeble 
action,  may  have  similar  results  in  congested  tissues,  or  in  patients 
whose  general  health  is  disordered. 

Specific  poisons,  introduced  locally  through  a  small  abrasion,  or 
present  in  the  blood  (e.g.  syphilis),  give  rise  to  special  forms  of  ulcer- 
ation to  be  subsequently  referred  to. 

In  the  case  of  a  simple  callous  ulcer,  many  causes  usually  act 
together  in  bringing  about  the  process.  These  ulcers  are  usuafly 
met  with  among  the  poor  of  large  cities — patients,  therefore,  ill-fed, 
ill-clad,  and  who  are  too  frequently  surrounded  by  faulty  hygienic 
arrangements,  or  are  the  subjects  of  chronic  alcoholism.  A  slight 
scratch, — say  on  a  leg,  which  is  the  seat  of  varicose  veins, — hardly 


Fig.  13. — Varicose  ulcer  (a)  with  varicose 
veins  of  the  leg.     (Tillmans.) 


D 


8  MANUAL  OF  SURGERY  chap. 


noticed  at  the  time,  gradually  enlarges  until  a  definite  small  wound  is 
produced ;  this  is  probably  neglected,  and,  above  all,  not  kept  clean, 
and  speedily  develops  into  a  chronic  ulcer.  In  such  a  case  the 
exciting  cause  is  insignificant,  but  the  attendant  local  and  general 
conditions,  all  tending  to  lower  vitality,  culminate  in  a  state  of 
things  which  would  otherwise  be  quite  inconsistent  with  its  trivial 
origin. 

Ulceration  of  mucous  surfaces  is  usually  of  a  specific  nature,  but 
may  be  induced  by  mechanical  irritation,  e.g.  ulcers  of  the  tongue 
from  sharp  teeth  or  badly-fitting  tooth-plates. 

Morbid  anatomy. — When  inflammation  occurs  in  the  skin  or 
mucous  membranes,  and  terminates  in  death  of  the  tissues,  the 
debris,  mixed  with  fluid,  escapes  from  the  surface  as  discharge.  In 
consequence  of  inflammation,  the  superficial  vessels  are  engorged 
and  many  are  thrombosed ;  leucocytes  and  fluid  exudate  pervade 
the  area  of  inflammation,  infiltrating  the  tissues,  and  penetrating 
among  the  epithelium  cells,  which  proliferate  and  are  cast  off. 
Deprived  of  their  blood-supply,  the  superficial  parts  and  numberless 
leucocytes  perish  and  undergo  molecular  disintegration.  If  the 
thrombosis  be  extensive  and  the  irritant  exciting  these  changes  acts 
with  marked  intensity,  large  or  small  masses  of  tissue  die  eu  masse, 
slough,  and  are  gradually  separated  by  the  phagocytic  action  of 
the  leucocytes.  An  ulcer  increases  in  size  so  long  as  its  causes 
remain  operative ;  inflammation  and  thrombosis  continue  at  the 
margins  and  in  the  base  of  the  sore,  which  gradually  increases  in 
area  and  depth.  The  rapidity  of  the  destructive  process  depends 
chiefly  on  the  nature  of  the  irritant ;  in  the  case  of  simple  ulceration 
it  is  usually  slow,  unless  putrefaction  occurs,  but  if  any  infective 
organism  is  present,  destruction  may  spread  with  alarming  rapidity, 
e.g.  hospital  gangrene.  Large  vessels  in  the  vicinity  of  an  ulcer 
usually  escape  destruction,  except  in  cases  of  an  infective  and 
rapidly-spreading  nature.  The  smaller  vessels  are  obliterated  by 
thrombosis,  and  are  destroyed  with  the  other  tissues.  Occasionally 
even  chronic  ulcers,  e.g.  gastric,  may  open  arteries,  and  give  rise 
to  profuse  or  fatal  hemorrhage.  Again,  varicose  ulcers  may  destroy 
the  wall  of  an  enlarged  vein. 

As  ulceration  extends  in  depth,  neighbouring  structures  may  be 
injuriously  affected;  thus,  chronic  ulcers  of  the  leg  not  uncommonly 
give  rise  to  periostitis  (Fig.  14,  p.  59),  or  even  to  caries  or  necrosis. 
Ulceration  on  mucous  surfaces  of  hollow  organs  may,  especially  if 
the  process  be  acute,  lead  to  perforations,  e.g.  typhoid  ulceration ; 
but  in  chronic  cases  adhesions  form  between  the  base  of  the  ulcer 


IV 


SIMPLE   OR   NON-SPECIFIC   ULCERATION 


59 


l.f" 


and  neighbouring  parts,  and  perforation   is  thereby  prevented,  e.g. 

chronic  gastric  ulcer.      As  soon  as  tlie  causes  inducing  ulceration 

have  ceased  to  act,  destruction  comes  to  an  end,  and  granulations 

spring   up   and    continue   to  grou'  until   the 

surface  is  reached,  when  healing — materially 

aided  by  contraction — is  completed  by  growth 

of  the  marginal  epithelium.     The  appearance 

of  the  base,  margins,  and  tissues  surrounding 

the  ulcer  differ  according  to  circumstances, 

and  will  be  stated  under  each  form. 

General  principles  of  treatment. — 
Constitutional  measures,  calculated  to  im- 
prove the  general  health  and  restore  lost 
■recuperative  power,  must  be  adopted.  Any 
dyscrasia  which  may  be  present,  although 
itself  not  the  actual  cause  of  the  ulceration, 
must  receive  its  appropriate  treatment. 

Among  the  poor,  simple  ulceration  is  too 
often  evidence  of  bad  and  improper  feeding, 
and  defective  sanitation.  In  such  cases  these 
defects  must  be  remedied  as  far  as  the  patient's 
circumstajices  will  permit.  Cod-liver  oil,  malt 
extract,  the  vegetable  bitters,  quinine  and  iron 
should  be  given  in  cases  of  anaemia  and 
general  debility.  Opium,  in  grain  doses  twice 
a  day,  is  a  most  valuable  remedy  in  some  cases. 
Under  its  use,  inflamed,  sloughy,  and  indolent 
ulcers  often  undergo  rapid  improvement. 

Local  measures.  —  All  local  sources  of 
irritation  must  be  removed,  and  every  en- 
deavour made  to  subdue  inflammation,  arrest 
the  destructive  process,  and  bring  about 
granulation.  Rest  and  elevation  are  im- 
portant in  all  cases. 

Antiseptics. — It  is  imperative  that  the  surface  be  rendered  aseptic, 
more  especially  in  those  ulcers  dependent  on  specific  organisms. 
The  presence  of  putrefactive  organisms  not  only  prevents  granulation, 
but,  on  account  of  the  irritation  produced,  favours  the  spread  of  the 
ulcer.  The  parts  round  the  wound  should  be  thoroughly  cleaned 
with  soap  and  water,  and  all  fatty  and  sebaceous  material  removed 
by  ether  and  ammonia ;  unless  this  be  thoroughly  done,  reinfection 
of  the  ulcer  will  take  place.     1  he  surface  of  the  sore  should  be 


Fig 


14- 


Osteoplastic  perios- 
titis of  the  tibia.  In  the  centre 
i=  a  smooth  area  which  formed 
the  floor  of  an  ulcer;  round 
this  the  new  hone  forms 
definite  nodules(Westminster 
Hospital  Museum,  No.  155). 
(Dr;iwn  by  C.  H.  Freeman.) 


6o  MANUAL  OF  SURGERY  chap. 

cleansed  by  hot  boracic  fomentations,  which  also  favour  the  separa- 
tion of  any  sloughs ;  or  the  surface  may  be  freely  swabbed  over  with 
pure  carbolic  acid,  or  a  strong  solution  of  it.  Chloride  of  zinc  (40 
grs.  ad  5i.)  is  an  efficient  antiseptic,  and  is  by  some  preferred  to 
carbolic  acid.  Asepsis  may  also  be  secured  by  dressing  the  sore  for 
a  few  days  with  carbolic  acid  solution  (5  per  cent),  or  i  :  1000  or 
I  :  2000  mercuric  solution.  When  putrefaction  has  been  arrested 
by  any  of  these  means,  reinfection  must  be  prevented  by  the  use  of 
mild,  unirritating  antiseptic  dressings,  e.g.  boracic  acid. 

When  a  chronic  ulcer  has  been  thoroughly  cleaned,  the  pain  so 
often  attending  it  is  materially  diminished.  In  the  case  of  infective 
ulceration,  more  energetic  measures  than  those  indicated  are  re- 
quired to  get  rid  of  the  irritating  organisms  (see  Hospital  Gangrene, 
Sloughing  Phagedena,  pp.  116,  118). 

Restoration  of  the  circulation  and  relief  of  venous  engorgement  is 
essential  in  all  cases.  Circulation  may  be  encouraged  by  gentle 
friction  and  massage  of  the  limb,  by  rest  and  elevation,  by  compres- 
sion with  bandages  or  strapping,  and,  in  the  case  of  varicose  veins, 
by  operation,  if  the  general  circumstances  of  the  case  permit  of  its 
performance  (see  chap.  i.  vol.  iii.). 

Compression  by  bandages  or  strapping  must  be  equable,  other- 
wise more  harm  than  good  will  result.  It  should  be  applied  from 
the  extremity  to  some  distance  beyond  the  ulcer — as  far,  indeed,  as 
the  circulation  is  impaired.  When  the  ulcer  has  been  dressed  in 
the  manner  to  be  presently  described,  an  ordinary  surgical  or  Martin's 
elastic  bandage  must  be  carefully  and  evenly  applied,  tightly  enough 
to  give  support  without  obstructing  the  veins.  It  should  be  put  on 
before  rising  in  the  morning,  and  may  be  dispensed  with  at  night. 
A  clean  thin  woollen  stocking  worn  beneath  the  bandage  and  changed 
every  day  serves  to  absorb  the  discharge  and  makes  the  patient 
more  comfortable.  Martin's  bandage  is  liable  to  set  up  eczema,  as 
it  prevents  evaporation  ;  this,  however,  is  less  likely  to  occur  if  it  be 
perforated.  The  bandage  should  be  lightly  applied,  as  it  becomes 
tighter  when  the  patient  walks  about  and  the  limb  fills  with  blood. 
Martin's  bandage  must  be  kept  thoroughly  clean,  and  dried  before 
reapplication,  and  must  not  be  used  with  any  greasy  dressing. 

Strapping  with  adhesive  plaster  is  an  excellent  means  of  com- 
pression. It  must  be  reapplied  every  day,  or  oftener,  according  to 
the  amount  of  discharge.  Compression  should,  when  possible,  be 
combined  with  rest  and  elevation. 

Dressings  applied  to  ulcers  must  be  antiseptic,  unirritating,  free 
from  grease,  and  must  be  changed  sufficiently  often  to  ensure  perfect 


IV  SIMPLE   OR   NON-SPFXIFIC   ULCERATION  6r 

cleanliness.  Antisci)tic  moist  warmth,  in  the  form  of  boracic  fomen- 
tations, combined  with  rest  and  elevation,  is  most  useful  in  the 
early  stages  of  ulceration,  in  chronic  cases  with  adherent  and  de- 
composing sloughs,  and  in  all  inflamed  and  sloughy  states.  The 
fomentations  should  be  thick,  large  enough  to  cover  a  considerable 
extent  of  the  surrounding  paits,  and  changed  every  four  hours  or 
oftener.  When,  by  their  use,  inflammation  has  subsided,  the  sloughs 
have  separated,  and  the  sore  has  been  brought  into  a  healthy  state, 
it  nmst  be  carefully  dressed  with  some  form  of  lotion. 

Boracic  acid  (4  grs.  ad  5i.)  is  the  best ;  it  keeps  the  surface  clean, 
but  does  not  cause  any  irritation.  Red  wash  (zinc  sulph.  grs.  2,  tr. 
lavand.  co.  n\  10,  aq.  ad  ^i.)  is  also  useful,  while  lead  and  opium  lotion 
may  be  used  if  there  is  much  pain.  Great  care  is  needed  in  the 
application  of  a  dressing.  The  surface  and  surrounding  parts  should 
be  gently  syringed  with  some  of  the  lotion  to  remove  all  discharge, 
it  should  then  be  lightly  covered  with  a  piece  of  lint  wetted  with  the 
solution,  which  should  only  cover  the  granulating  surface ;  for  if  it 
be  too  large,  the  growing  epithelium  at  the  edges  is  macerated,  and 
healing  retarded.  Over  the  lint  a  piece  of  protective  is  placed,  and 
should  project  about  one-eighth  of  an  inch  beyond,  this  again  is 
covered  with  a  thin  layer  of  salicylic  wool,  and  the  whole  retained 
in  position  by  a  bandage  lightly  and  evenly  applied  from  below  up- 
wards. The  dressing  should  be  changed  each  day,  or  oftener  if 
there  is  much  discharge. 

Ointments,  spread  on  butter-cloth,  are  much  used  by  some ;  but 
they  have  the  disadvantage  of  being  greasy,  and  not  easily  removed. 
They  should  be  made  with  vaseline,  paraffin,  or  lanolin,  and  never 
with  ordinary  lard,  which  rapidly  putrefies.  Boracic  ointment  is  the 
most  useful. 

When  the  granulating  surface  is  weak,  the  granulations  being 
flabby,  cedematous,  and  exuberant,  it  should  be  stimulated  with  red 
wash,  or  lightly  touched  with  a  stick  of  silver  nitrate. 

Dr.  Findlater,  of  Edgware,  has  been  very  successful  In  treating 
large  chronic  ulcers  by  the  following  plan  : — The  ulcer  is  covered 
with  a  piece  of  coarse  muslin  or  leno  (which  has  been  cleansed  and 
softened  in  boracic  or  carbolic  solution)  applied  from  below  up  as  a 
bandage,  and  made  to  exert  firm  pressure.  This  is  not  removed  for 
a  fortnight,  and  may  remain  untouched  even  longer.  Outside  it  a 
piece  of  lint,  saturated  with  weak  boracic  solution  or  red  wash,  is 
applied,  covered  with  oiled  silk  and  kept  in  position  by  a  few  turns 
of  a  bandage  ;  this  outside  dressing  is  reapplied  once  or  twice  daily 
according  to  the  amount  of  discharge.      I  have  given  this  method 


62 


MANUAL   OF   SURGERY 


CHAP. 


some  attention,  and  have  been  surprised  with  the  excellent  results 

obtained,  especially  after  first 
grafting  the  ulcer  (f  igs.  1 5, 
16).  The  resulting  scar,  after 
skin  grafting  and  treatment  by 
this  method,  closely  resembles 
true  skin,  and  is  certainly 
superior  to  that  obtained  by 
any  other.  The  discharge 
from  the  ulcer  oozes  through 
the  meshes  of  the  muslin,  and 
must  be  washed  away  each 
time    the    outer    dressing    is 


Fig.  15. — A  chronic  ulcer  of  the  leg  of  thirty 
years'  duration  in  a  man  set.  fifty-one. 
(Photograph  by  Mr.  Budd.) 


changed 


If  there  is  much 
discharge,  the  meshes  of  the 
muslin  must  be  coarse.  The 
muslin  exercises  equable  com- 
pression on  the  edges  and  base 
of  the  ulcer,  and  has  the  ad- 
vantages of  strapping  without 
confining  the  discharge.  The 
ulcer  may,  if  clean  enough,  be 
first  grafted.  I  have  had 
many  opportunities  of  appre- 
ciating the  success  of  this 
plan  in  cases  of  ulcer  under 
my  care,  and  have  been  much 
struck  with  the  rapidity  with  which  healing  has  occurred,  even 
in  those  of  the  most  unpromising  nature. 


Fig.  16.— The  same  leg  as  Fig.  15,  taken  thirteen 
days  after  skin  grafting.  The  grafts  were  pro- 
tected by  Findlater's  method,  and  tlie  dressing 
was  left  untouched  for  ten  days.  The  scar 
subsequently  became  quite  sound  and  closely 
resembled  normal  skin  in  appearance.  (Photo- 
graph by  Mr.  Budd.) 


IV  SIMPLK    OR   XOX-SPKCIFK:  ULrRRATIOX  63 

Dr.  Findlaicr  also  uses  this  method  in  the  treatment  of 
burns. 

TJie  oxygen  treatment,  introduced  by  Dr.  Stoker,  has  in  his  hands 
proved  very  successful.  The  part  on  which  the  ulcer  is  situated  is 
isolated  in  a  chamber  containing  an  atmosphere  of  pure  air  charged 
with  40  per  cent  oxygen.  Ozone  is  said  to  give  better  results. 
The  treatment  is  continuous,  and  takes  a  long  time  to  effect  hea'l- 
ing,  but  should  be  tried  when  other  means  fail — doubtless  the 
enforced  and  prolonged  rest  does  much  good. 

Skin  grafting. — Healing  may  be  considerably  hastened,  and  a 
sounder  scar  with  diminished  contraction  ensured,  by  skin  grafting. 
The  grafts  may  be  taken  from  the  patient,  or  from  another  person. 
In  the  latter  case,  every  care  must  be  taken  to  select  a  ])erfectly 
healthy  individual ;  but  the  practice  is  objectionable,  and  has  been 
known  to  convey  syphilis  to  the  patient  (p.  170). 

Reverdins  method — Epithelial  grafts. — The  ulcer  must  be  thor- 
oughly clean,  and  the  surface  (usually  the  arm  or  thigh)  from  which 
the  grafts  are  to  be  taken  must  be  rendered  aseptic.  Minute  por- 
tions of  epidermis  are  shaved  off  or  snipped  off  with  a  fine  pair  of 
scissors  curved  on  the  flat,  while  the  skin  is  caught  up  in  a  fine 
pair  of  forceps ;  these  are  then  laid  on  the  ulcer,  the  several 
grafts  being  placed  about  half  an  inch  apart.  A  piece  of  protective 
cleansed  in  carbolic  or  boracic  solution  is  placed  over  all,  and  a  light 
dressing  applied  and  left  undisturbed  for  three  or  four  days,  when 
the  situation  of  those  grafts  which  have  "  taken  "  will  be  indicated 
by  a  slight  depression,  though  they  may  not  be  distinguishable,  since 
the  opaque  superficial  cells  will  probably  have  desquamated.  In  a 
day  or  two,  however,  small  white  areas,  surrounded  by  blue  and  pink 
zones  (epithelial  islets),  are  distinctly  visible.  The  new  epithelium 
spreads  over  the  surface  and  neighbouring  islets  coalesce.  Such  a 
scar  is  not  very  stable,  and  may  break  down  from  slight  causes. 

Thiersch's  method  produces  more  rapid  healing,  a  more  stable 
scar,  and  minimises  the  contraction  of  the  ulcer.  It  may  be  advan- 
tageously employed  in  operations  where  the  edges  of  the  wound 
cannot  be  approximated,  and  in  plastic  surgery. 

Strict  asepsis  and  a  healthy  state  of  the  wound  and  patient  are 
essential 

The  granulations  and  healing  edge  of  the  ulcer,  if  unhealthy, 
must  be  scraped  away  or  shaved  off  with  a  razor,  so  that  the  firm 
young  fibrous  tissue  at  its  base  is  exposed.  A  piece  of  clean  pro- 
tective is  then  placed  on  the  denuded  surface,  and  over  this  sponges 
are  firmly  bandaged  to  arrest  ail  haemorrhage.     It  is  not,  however, 


64  MANUAL   OF   SURGERY  chap. 

by  any  means  necessary  to  scrape  away  the  granulations  provided 
they  be  clean  and  healthy,  for  the  grafts  will  grow  on  them  perfectly 
well. 

The  grafts  are  most  conveniently  taken  from  the  inner  side  and 
front  of  the  thigh.  A  broad  flat  razor,  wetted  with  boracic  solu- 
tion, or  .5  per  cent  salt  solution,  to  prevent  them  sticking,  is  made 
by  a  gentle  sawing  movement  to  cut  large  grafts,  including  about 
half  the  thickness  of  the  skin,  which  is  put  on  the  stretch  by  an 
assistant.  This  just  divides  the  tops  of  the  papillae,  and  causes 
slight  oozing  from  the  cut  surface.  The  grafts  tend  to  curl  up, 
and  may  be  best  apphed  by  floating  them  from  the  razor  on  to 
the  surface,  on  which  they  are  placed  raw- surface  downwards. 
The  several  grafts  should  slightly  overlap,  and  the  whole  sore  be 
completely  covered.  The  curled-up  margins  may  be  straightened 
out  by  a  probe  and  forceps.  The  wound  is  then  covered  with 
protective,  which  has  been  cleaned  in  boracic  solution.  Outside 
this  a  layer  of  salicylic  or  boracic  wool  is  applied,  and  the  whole 
dressing  firmly  bandaged  on  and  left  undisturbed  for  five  or  six 
days,  when  the  grafts  will  be  found  to  have  taken.  The  muslin 
bandage,  as  described  on  p.  61,  is  an  excellent  means  of  keeping 
the  grafts  in  position  and  ensuring  rest.  Complete  rest  and 
freedom  from  all  sources  of  local  irritation  must  be  observed  for 
some  weeks,  or  else  the  scar  may  break  down.  The  wounds  left 
by  removal  of  the  grafts  must  be  covered  with  boracic  ointment 
or  iodo-vaseline,  and  left  untouched  for  six  or  seven  days,  when 
healing  will  have  occurred. 

Varieties  of  simple  ulcer. — The  healthy  op  healing:  sore 
is  nothing  more  than  a  granulating  wound.  The  outline  varies 
in  shape,  but  is  usually  circular  or  ovoid ;  the  surrounding  tissues 
have  lost  all  trace  of  inflammation,  but  some  of  the  vessels  may  be 
hypereemic,  and  there  may  be  slight  staining.  The  edge  is  not 
indurated,  but  is  regular,  gradually  bevelled  towards  the  surface, 
and  presents  three  zones  distinguished  by  their  colour.  The  inner- 
most zone  is  composed  of  a  single  layer  of  epithelium  cells,  advancing 
over  the  granulating  surface  from  the  margin ;  this  zone  is  red,  and 
is  surrounded  by  a  thicker  layer  of  cells  of  a  bluish  tint,  the  colour 
being  due  to  the  absence  of  the  horny  cells  of  the  epidermis. 
Externally,  where  the  epithelium  cells  form  a  thick  layer  and  the 
horny  cells  are  present,  the  colour  is  dead  white ;  this  zone  may  be 
considerably  increased  in  area  by  maceration  of  the  superficial  cells 
if  wet  dressings  are  applied.  The  base  of  a  healthy  sore  is  quite 
supple,  and  its  contraction  accelerates   the  healing  process.     The 


IV  SIMPLE   OR   NON-SPECIFIC   ULCERATION  65 

surface  is  level  and  covered  with  florid  granulations,  and  here  and 
there  may  be  seen  uiidcstroyed  islets  of  epithelium.  The  discharge 
is  very  scanty  and  is  pure  pus.  There  is  no  pain,  even  if  the 
surface  of  the  sore  be  touched. 

Indolent  or  callous  ulcers  are  usually  met  with  in  the  lower 
third  of  the  leg  in  patients  beyond  middle  life,  especially  in  associa- 
tion with  varicose  veins.  The  base  and  edges  are  hard  and 
indurated ;  the  latter  are  steep-cut,  irregular,  and  raised,  and  show 
no  signs  of  epithelial  proliferation.  Induration  is  due  to  the 
development  of  new  fibrous  tissue  which  acts  detrimentally  in  two 
ways:  (i)  by  preventing  contraction,  and  (2)  by  narrowing  the 
vessels  and  preventing  the  due  supply  of  blood.  The  induration 
extends  for  some  distance  beyond  the  ulcer,  and  the  tissues  are 
often  congested  and  hyperaemic.  The  base  is  considerably  below 
the  level  of  the  edge ;  it  is  adherent  to  subjacent  parts  and  covered 
by  unhealthy  granulations  exuding  a  sanious,  purulent  discharge. 
The  indolent  ulcer  is  very  chronic  and  may  completely  surround  the 
limb,  being  then  often  incurable  (annular  ulcer).  It  is  generally 
painless,  but  may  cause  much  suffering,  either  as  the  result  of  im- 
plication of  the  nerve  endings  in  the  connective  tissue,  or,  in  the 
case  of  the  leg,  from  periostitis  of  the  bone  beneath  (Fig.  14,  p.  59). 

Treatment. — The  surface  of  the  ulcer  and  parts  around  must 
be  rendered  aseptic,  and  an  attempt  made  to  get  rid  of  the  indura- 
tion and  depress  the  edges.  This  may  be  accomplished  by  rest, 
elevation,  or  massage,  and  especially  by  bandaging  or  strapping. 
Strapping  exerts  equable  compression,  thereby  encouraging  the 
circulation  and  promoting  absorption  of  the  effused  lymph  in  the 
indurated  edges  and  base  of  the  ulcer.  Findlater's  plan  of  treat- 
ment is  very  useful  (Figs.  15  and  16,  p.  62).  Some  surgeons  strongly 
recommend  stimulation  of  the  surrounding  congested  parts  by  means 
of  blisters.  When  the  surface  assumes  a  more  healthy  appearance, 
stimulating  lotions,  e.g.  red  wash,  should  be  applied,  or  it  may  be 
occasionally  touched  with  silver  nitrate.  Opium  internally  is  often 
of  great  use,  and,  occurring  as  these  ulcers  so  frequently  do  in  the 
poor  and  half-starved,  every  effort  must  be  made  to  ensure  better 
living  and  more  healthy  surroundings,  treatment  which  is  unfor- 
tunately more  easily  recommended  than  followed.  Indolent  ulcers 
extending  completely  round  the  limb  may  necessitate  amputation. 

The  weak  ulcer  is  covered  with  exuberant  pale,  flabby,  gela- 
tinous granulations  which  project  beyond  the  surface,  and  are  apt 
to  slough  and  break  down  on  slight  irritation.  Such  a  condition  is 
not  uncommonly  seen  in  debilitated  patients. 

VOL.  I  F 


66  MANUAL  OF   SURGERY  chap. 

Tj-eatment. — This  form  of  ulcer  requires  stimulating  with  some 
astringent  lotion,  such  as  red  wash,  or  by  touching  with  the  solid 
nitrate  of  silver.  Rest,  elevation,  and  strapping  are  also  necessary. 
If  these  measures  fail,  the  surface  should  be  sharp-spooned. 

The  irritable  ulcer  is  most  usually  met  with  at  the  lower  third 
of  the  leg  or  behind  the  outer  ankle.  It  is  especially  prone  to  occur 
in  women,  and  has  many  of  the  characters  of  an  indolent  ulcer. 
The  surface  is  often  in  a  dirty  sloughing  condition,  discliarging  a 
small  quantity  of  sanious  pus. 

The  pain  may  be  extreme,  especially  at  night ;  it  is  dependent 
on  exposure  of  the  nerve  endings,  and  to  their  irritation  by  the 
chemical  products  of  putrefaction,  and  also  to  their  involvement  in 
the  new  fibrous  tissue. 

Treatment. — Free  scraping  of  the  surface  or  the  application  of 
strong  carbolic  or  nitric  acid  is  indicated.  In  cases  of  severe  pain 
a  tenotome  may  be  passed  beneath  the  base  of  the  ulcer,  which  is 
then  freed  from  its  deep  connections  and  the  nerves  divided.  If 
the  pain  can  be  located  at  certain  points  by  running  a  probe 
over  the  surface  of  the  ulcer,  it  may  be  stopped  by  passing  a  fine 
knife  under  such  tender  areas  as  recommended  by  Hilton.  In  less 
severe  cases  lead  and  opium  lotions  may  be  effectual.  The  internal 
administration  of  opium  is  often  necessary  and  most  beneficial. 

Varicose  ulcer. — Ulcers  dependent  on  the  presence  of  varicose 
veins  are  so  named  (Fig.  13,  p.  57).  They  present  the  ordinary 
characters  of  the  indolent  ulcer  (p.  65). 

Treatment. — The  varicose  ulcer  must  be  treated  on  the  same 
lines  as  the  indolent.  If  circumstances  permit,  the  varicose  veins 
should  be  operated  on  ;  at  the  same  time  the  surface  of  the  ulcer  is 
sharp -spooned,  thoroughly  cleansed,  and  dressed  antiseptically. 
When  the  dressings  are  removed  at  the  end  of  a  week  or  ten  days 
the  surface  will  be  found  granulating  healthily,  and  in  the  case  of  a 
small  ulcer  practically  healed. 

Hsemorrhagie  uleer  is  spoken  of  in  cases  where  hemorrhage 
from  the  granulations  and  into  the  base  of  the  ulcer  give  it  a  purplish 
colour.  The  haemorrhage  sometimes  occurs  at  the  menstrual 
period,  and  the  general  appearance  of  the  sore  is  sometimes  sugges- 
tive of  sarcoma. 

Treatme?it. — As  these  ulcers  usually  occur  in  anaemic  women 
they  demand  the  exhibition  of  iron  and  tonics  coupled  with  good 
food.  Locally,  bandaging  or  strapping  is  beneficial.  Their 
occasional  dependence  on  scurvy  should  be  borne  in  mind  with  regard 
to  treatment. 


IV  SPECIFIC   ULCERS   DEPENDENT  ON   DVSCRASIA  67 

Inflamed  ulcer. — In  some  cases  simple  ulcers  may  be  accom- 
lanied  by  considerable  acute  inflammation,  with  its  local  and 
:onstitutional  sym[)toms.  Tlie  destruction  of  tissue  is  rapid  and 
ihe  discharge  copious,  often  mixed  with  blood  and  slireds  of  slough. 
Putrefaction  is  common.  Inflamed  ulcers  are  chiefly  met  with  in 
drunkards  and  jKTsons  of  bad  constitution. 

The  sloughing  ulcer  is  an  exaggerated  form  of  the  inflamed, 
and  is  usually,  though  not  always,  of  a  specific  nature  (see  Sloughing 
Phagedajna  and  Hospital  Gangrene,  pp.  118,  116). 

Treatment. — Inflamed  and  sloughing  ulcers  must  be  treated  by 
absolute  rest  and  elevation  of  the  part,  which  should  be  continuously 
fomented  with  hot  boracic  acid.  If  there  is  much  exudation  into 
the  surrounding  tissues,  incisions  may  become  necessary  for  the 
relief  of  tension. 


SPECIFIC    ULCERS    DEPENDENT    ON    SOME    CONSTITUTIONAL 

DVSCRASIA 

Ulceration  forms  one  of  the  clinical  features  of  some  diathetic 
states.  Such  ulcers  present  certain  peculiarities  of  appearance, 
situation,  and  progress  which  readily  distinguish  them  from  each 
other  and  from  simple  ulcers. 

Ulceration  of  mucous  membranes  is  usually  of  a  specific  nature. 

Syphilitic  ulcers,  see  p.  184. 

Tubercular  ulcers,  see  p.  152. 

Scorbutic  ulcers  are  accompanied  by  the  usual  manifestations 
of  scurvy  and  are  caused  by  the  most  trivial  injuries  or  scratches,  or 
originate  in  a  scar.  They  are  often  seen  about  the  mouth  and  may 
cause  extensive  sloughing  of  the  gums  and  mucous  membrane. 
Scorbutic  ulcers  are  of  a  livid  colour.  The  surrounding  tissues  are 
swollen  and  oedematous  and  the  ulcer  tends  to  spread.  The 
surface  is  covered  with  unhealthy  granulations  and  exudes  a 
foetid  sanious  discharge  which  often  forms  a  thick  spongy  crust, 
removal  of  which  excites  free  bleeding.  The  crust  rapidly 
re-forms. 

Treatment. — The  ulcerated  surface  must  be  kept  clean  and  free 
from  all  sources  of  irritation.  The  general  treatment  is  that  of 
scurvy,  for  which  the  reader  is  referred  to  a  work  on  medicine. 

Diabetic  ulcers. — Diabetic  patients  are  very  prone  to  sloughy 
ulceration,  often  from  very  slight  causes,  e.g.  blistering.  A  dark- 
coloured  slough  may  form,  which  gradually  extends  in  depth  and 
area.     Putrefaction  is  common  unless  cleanliness  be  observed,  and 


68  MANUAL  OF  SURGERY  chap. 

the  process  shows  a  tendency  to  spread  and  very  Httle  towards 
heaUng.     Pain  is  usually  severe,  but  may  be  absent  (see  p.  85). 

Treatment. — Unirritating  antiseptic  lotions  should  be  freely  used 
and  the  sore  treated  on  the  general  principles  laid  down  (p.  59). 
Opium  must  be  given  in  large  doses  and  the  general  disease  treated. 

Gouty  ulcers. — The  subjects  of  gout  are  specially  prone  to 
chronic  congestion  and  inflammation,  and  not  infrequently  develop 
very  indolent  superficial  ulcers  about  the  lower  third  of  the  leg. 
Such  ulcers  are  often  surrounded  by  eczematous  skin  {eczematous 
ulcer).  The  discharge  is  thin,  and  often  contains  urate  of  soda. 
In  some  cases  the  skin  inflames  over  a  "chalk-stone,"  and  a  deep 
ulcer  results,  which  constantly  discharges  masses  of  the  salt. 

Gouty  ulcers  are  very  persistent,  remain  stationary  for  a  long 
time,  and  tend  to  recur  again  and  again  from  the  most  trivial 
causes. 

Treatment. — Rest,  with  the  application  of  a  mild  unirritating 
lotion,  such  as  boracic  acid,  is  the  best  local  treatment.  The  diet 
must  be  carefully  regulated,  beer  and  wine  being  interdicted,  and 
the  quantity  of  meat  and  pastry  Hmited.  Saline  aperients,  colchicum 
and  citrate  of  potash,  should  be  prescribed. 

ULCERS    DEPENDENT    ON    LESIONS    OF    THE    NERVOUS    SYSTEM 

Certain  ulcerations  may  occur  in  connection  with  wounds  of 
nervous  trunks  and  in  diseases  of  the  central  nervous  system, 
with  which  they  will  be  described. 

ULCERATION    AND    SLOUGHING    DEPENDENT    ON    LOCAL    INFECTION 

Inoculation  with  certain  micro-organisms  may  lead  to  extensive 
sloughing  of  the  tissues,  perhaps  more  closely  allied  to  gangrene 
than  to  ulceration.     These  conditions  will  be  described  in  chap.  vii. 

ULCERS    DEPENDENT    ON    THE    PRESENCE    OF    TUMOURS 

Cancer  and  sarcoma  may  gradually  infiltrate  and  destroy  the 
skin  so  that  the  substance  of  the  tumour  is  exposed.  Any  tumour 
may  cause  ulceration  of  the  skin  over  it  as  the  result  of  stretching, 
or  from  pressure  on  the  vessels.  Malignant  tumours  may,  when 
exposed,  fungate  on  the  surface ;  or  the  ulceration  may  extend 
deeply  into  their  substance  and  cause  a  large,  crateriform,  foul 
ulcer  (Fig.  62,  p.  254). 


IV  ULCERS   DEPENDENT  ON  TUMOURS  69 

Soft  growths  are  more  likely  to  fungate.  In  any  case  the  growth 
of  the  tumour  more  than  makes  up  for  the  loss  by  ulceration,  so 
that  it  continues  to  increase  in  size. 

Rodent  ulcer  is  a  special  form  of  epithelioma,  slow  destruction 
of  all  tissues  in  its  neighbourhood  being  the  chief  clinical  feature. 

For  further  information,  see  pp.  232,  253. 


CHAPTER   V 

Gangrene  or  Mortification 

Death  of  a  portion  of  the  body  without  previous  disintegration  of 
its  structure  is  known  as  Gangrene  or  Sloughing,  the  latter  term 
being  usually  reserved  for  death  of  small  areas  only ;  the  dead 
portion  is  known  as  a  slough  or  sphacelus.  Gangrene  may  occur 
in  any  part  of  the  body,  and  under  such  different  condition^,  that 
the  effects  and  symptoms  it  produces  vary  within  the  widest  limits. 

Etiology. — In  most  cases  of  gangrene  several  causes  combine  to 
bring  about  the  death  of  the  part ;  some  are  adjuvants  only,  but  all 
have  this  in  common — they  lower  the  vitality  of  the  part,  in  the 
majority  of  cases,  by  interfering  with  the  circulation  through  it. 
Thus,  the  lessened  vitality  and  cardiac  weakness  of  old  age,  coupled 
with  arterial  degeneration  leading  to  thrombosis  and  complete 
occlusion  of  the  vessels,  are  the  factors  in  the  production  of  senile 
gangrene. 

The  predisposing'  causes  are  those  which,  by  lowering  general 
or  local  vital  activity,  favour  the  occurrence  of  gangrene  in  the 
presence  of  exciting  causes.  Old  age,  cardiac  insufficiency,  general 
disease  of  the  arterial  system,  deficient  nervous  influence,  renal 
disease,  diabetes,  and  many  of  the  acute  fevers  are  predisposing 
causes  of  gangrene  which,  under  such  conditions,  may  occur  from 
quite  trivial  causes,  e.g.  a  small  wound. 

Determining'  causes.  —  Si?nple  acute  i?i/lamfnation  of  healthy 
tissues  very  rarely  results  in  gangrene,  but  it  may  do  so  if  from  any 
cause,  e.g.  diabetes,  nutrition  is  affected.  Inflammation  dependent 
on  certain  micro-organisms  may  be  so  intense,  and  accompanied  by 
so  much  exudation,  that  the  vessels  are  compressed,  and  gangrene 
results,  e.g.  gangrene  of  the  skin  in  cellulitis;  or  the  corrosive 
action    of  the   chemical  products  of  the  organisms    may   kill   the 


CHAP.  V 


GANGRENE   OR    MORTIFICATION 


71 


tissues,  e.g.  hospital  gangrene.  Thus  the  causes  of  inflammation 
are  also  causative  factors  in  some  cases,  but  not  in  all,  for  the 
process  may  occur  independently  of  any  antecedent  inflammatory 
condition. 

Severe  mechanical  (^\^.  19,  p.  "]  ^)  and  chemical  injuries  and  extremes 
of  heat  and  cold  induce  gangrene,  either  directly  in  consequence  of  the 
actual  damage  done  to  the  tissues  or  vessels, 
or  secondarily,  as  a  result  of  inflammation,  the 
vitality  of  the  parts  having  been  seriously  im- 
paired by  the  injury.  A  part  severely  crushed 
is  killed  outright  ;  and  even  if  the  larger 
vessels  are  not  ruptured,  circulation  through 
them  is  impeded,  and  the  blood  is  no  longer 
capable  of  passing  along  them  owing  to  the 
damaged  state  of  their  walls. 

Pressure  on  the  tissues  is  primarily  exer- 
cised at  the  expense  of  the  fluids,  viz.  the 
blood  and  lymph.  The  first  eff'ect  of  in- 
jurious pressure  will  be  felt  by  the  thin- 
walled  veins ;  the  circulation  through  them 
is  impeded,  and  oedema  results,  thereby  in- 
creasing the  pressure,  and  leading  to  arterial 
obstruction.     The  ill-eff'ects  of  pressure  are   ^"'•'Z-,~S^?^'''"'f '^*^*^"^,:! 

■T  resulting  irom  poisoning  by 

specially  noticeable  in  patients  in  bad  general       the  sting  of  a  weaver  fish 
health,  or  in  parts  which  from  any  cause  are 
not  properly  nourished,  e.g.  bed-sores  in  old 
and  feeble  people  and  on  paralysed  limbs. 

Tension  is  a  form  of  pressure,  and  plays 
an  important  part  in  gangrene  resulting  from 
acute  inflammation  ;  thus,  in  acute  cellulitis 
the  tension  of  the  inflammatory  exudate 
compresses  the  blood-vessels  running  to  the 
skin,  which  consequently  sloughs  (p.  129). 

/;/  obstruction  to  the  circulation  the  im- 
pediment may  be  in  the  veins  or  arteries, 
and  may  be  due  to  a  variety  of  causes.  From 
whatever  cause  arising,  diminution  in  the  quantity  of  blood  passing 
along  a  vessel  is  compensated  for  by  the  establishment  of  collateral 
circulation ;  should  this  be  insufficient,  the  effects  will  depend  upon 
the  extent  to  which  the  circulation  is  embarrassed ;  if  the  impedi- 
ment is  great,  gangrene  must  result. 

Interference  with  the  circulation  through  the  veins  may  be  due 


(  Track  in  us  draco,  Li  n  n .  )• 
The  poisonous  mucus  is 
lodged  in  a  deep,  double 
groove  in  the  spines  of  the 
dorsal  fin  and  opercular 
spines.  These  fish  are 
dreaded  by  fishermen  on 
account  of  the  dangers  ihey 
attribute  to  a  wcund  from 
one  of  the  spines  which  they 
cut  oflf  before  handling  the 
fish.  Swelling  rapidly  ex- 
tends to  the  shoulder,  accom- 
panied by  pain.  Fishermen 
say  that  smart  friction  with 
oil  soon  restores  the  part  to  a 
normal  condition.  Sce/'ts/tes 
0/  ttie  British  Islands,  by 
Couch.  (Drawn  by  C.  H. 
Freeman.) 


72  MANUAL  OF  SURGERY  chap. 

to  pressure  from  without,  injury,  or  thrombosis.  Obstruction  of  an 
artery  is  more  serious  than  is  that  of  a  vein,  because  the  venous 
channels  are  more  numerous  and  larger  than  the  arterial,  and  if 
gangrene  is  to  follow  venous  obstruction  many  important  vessels 
must  be  implicated.  It  is  highly  probable  that  gangrene  from  venous 
obstruction,  independently  of  arterial  does  not  occur. 

The  position  of  arterial  obstruction  is  a  matter  of  importance ; 
thus,  if  the  popliteal  be  occluded  at  its  upper  part,  the  safety  of  the 
limb  is  imperilled  owing  to  the  scanty  collateral  circulation  about 
the  knee ;  whereas  obstruction  of  the  femoral  at  Scarpa's  triangle 
is  readily  compensated  for  through  the  profunda  and  vessels  at  the 
back  of  the  limb. 

Obstruction  to  the  arterial  supply  may  be  due : — 

(i)  To  causes  acting  from  ivithout^  e.g.  ligature  or  pressure. 

(2)  To  causes  from  within^  e.g.  thrombosis  or  embolism. 

(3)  To    causes    acting  on    the    walls ^    e.g.    injury,    calcification, 

obliterative  arteritis. 

(4)  To  arterial  spasm,  as  in  Raynaud's  disease  (Fig.  20,  p.  83)  and 

ergot  gangrene. 

(5)  To  a  mixture  of  these  conditions. 

Defective  innervation  of  the  tissues  may  be  an  exciting  as  well  as  a 
predisposing  cause  of  mortification  ;  the  gangrenous  patches  which 
form  so  quickly  and  extend  so  deeply  in  cases  of  injury  to  the  spinal 
cord,  and  the  sloughing  of  the  cornea  after  injury  of  the  fifth  cranial 
nerve,  are  well-known  instances.  Raynaud's  disease  is  probably  due 
to  central  lesions  of  the  cord  inducing  vaso-motor  spasm ;  and 
diabetic  gangrene  is  sometimes  dependent  on  peripheral  neuritis. 
The  mode  in  which  nervous  influences,  or  their  withdrawal,  maintain 
or  diminish  the  vitality  of  the  tissues  is  at  present  undetermined, 
and  it  is  more  than  probable  that  gangrene  dependent  on  injury  of 
nervous  matter  is  of  complex  production.  The  existence  of  trophic 
nerves — filaments  directly  responsible,  as  it  were,  for  the  due 
nourishment  of  the  tissue  elements — is  at  present,  although  believed 
in  by  most,  not  proved ;  but  assuming  such  to  exist,  it  is  easy  to 
understand  how  their  damage  would  result  in  necrosis  of  the  parts 
they  supply.  Those  who  deny,  or  at  any  rate  doubt,  the  existence 
of  such  direct  trophic  influence,  attribute  the  gangrene  following 
nervous  lesions  to  vaso-motor  paralysis  and  consequent  dilatation  of 
the  vessels  leading  to  chronic  congestion  and  impaired  circulation ; 
this  phenomenon  doubtless  occurs,  and  contributes  to  the  occurrence 
of  gangrene,  but  is  in  all  likelihood  contributory  only. 

In  Raynaud's  disease  and  in  ergotism,  irritation  of  the  sensory 


V  GANGRENE  OR   MORTIFICATION  73 

nerves  Induces  a  condition  of  vaso-motor  spasm  limiting  the  supply 
of  blood,  and  such  limitation,  if  persistent  or  frequently  repeated, 
terminates  in  gangrene. 

Specific  tnkro-organistns  may  induce  acute  inflammation  terminating 
in  death.  This  result  is  partly  due  to  the  peptonising  action  of  the 
organism,  and  partly  to  the  tension  exercised  by  the  inflammatory 
exudate.  Gangrene  of  this  class  is  of  the  spreading  variety  and 
highly  dangerous.  The  products  of  putrefaction  are  capable  of 
inducing  extensive  sloughing  of  the  tissues  with  which  they  come  in 
contact. 

Varieties. — Gangrene  induced  by  causes  acting  directly  on  the 
dead  part,  e.g.  mechanical  injury,  cold,  is  said  to  be  direct.  When 
the  cause  acts  at  a  distance,  e.g.  circulatory  obstruction,  the  gangrene 
is  said  to  be  indirect.  Co?istitutional  gangrene  is  due  to  some  general 
condition,  e.g.  diabetes.  Ififlanwiatory  gangrene  is  the  outcome  of 
antecedent  inflammation  either  of  a  simple  or  specific  nature. 

Dry  gangrene  is  usually  seen  in  peripheral  parts  in  which 
there  is  little  moisture  ;  and  as  this  is  lost  by  evaporation,  the 
dead  part  becomes  mummified. 

Moist  gangrene  occurs  in  all  internal  tissues,  and  in  cases 
where  evaporation  of  fluids  does  not  occur. 

General  local  condition  of  gangrenous  parts. — The  general 
appearance  of  gangrenous  tissues  varies  according  to  whether  the 
gangrene  be  dry  or  moist ;  but  in  all  cases  the  signs  diagnostic  of 
death  are  the  same. 

Sensibility  is  completely  lost  in  dead  tissues.  When  gangrene  is 
threatened  there  is  often  a  feeling  of  weight,  numbness  or  coldness 
of  the  part,  and  sometimes  acute  tingling  or  burning  pain  is  present. 
The  presence  or  absence  of  pain,  and  its  degree,  depend  on  the 
rapidity  of  the  process  and  the  integrity  or  otherwise  of  the  nervous 
supply.  Pain  in  a  gangrenous  part  may  be  merely  referred  to  it  in 
the  same  way  that  a  patient  after  amputation  of  the  leg  may  refer 
pain  to  the  toes ;  it  may  also  be  due  to  the  continued  activity  of 
the  nervous  elements  which  have  retained  their  vitaUty  longer  than 
less  important  structures. 

Loss  of  heat  necessarily  follows  on  the  death  of  any  part,  its 
temperature  then  depending  on  that  of  its  surroundings. 

Loss  of  function. — So  long  as  any  muscular  power  remains  in 
a  gangrenous  part  movement  is  possible.  Thus,  in  spreading 
traumatic  gangrene,  a  disease  especially  spreading  along  cellular 
planes,  movement  of  the  limb  is  easy  since  the  muscles  are 
unaffected. 


74 


MANUAL  OF   SURGERY 


CHAP. 


The  colour  of  gangrenous  parts  usually  varies  from  greenish- 
brown  to  black,  and  is  due  to  the  formation  of  sulphide  of  iron 
produced  by  the  action  of  sulphuretted  hydrogen  on  the  iron  of  the 
red  corpuscles.  If  the  amount  of  blood  in  the  part  be  very  small, 
as  in  cases  of  arterial  obstruction,  the  colour  is  often  at  first  of  a 
tallowy,  dead  white  ;  sooner  or  later,  however,  the  dead  part  becomes 
flecked  by  streaks  and  maculae  of  brown  and  black  which  increase 
in  size  and  number  and  fuse,  and  so  change  the  colour  of  the  whole 
part. 

The  appearance  as  regards  swelling,  etc.,  depends  upon  whether 
the  gangrene  is  dry  or  moist. 

Dry  gangrene  (Fig.  i8). — The  dead  part,  losing  fluid  by  evapora- 
tion, becomes  hard  and  horny,  shrivels  up,  and  closely  resembles  the 

tissues  of  a  mummy.  Swelling  and 
decomposition  are  absent,  and  no 
blebs  form  on  the  surface,  which  has 
a  peculiar  greasy  feel,  and  exhales  a 
musty  odour. 

Moist  gangrene  differs  materially 
from  dry,  the  difference  being  due  to 
the  presence  of  fluid  in  the  tissues 
and  consequent  putrefactive  changes. 
The  part  quickly  swells,  undergoes 
rapid  decomposition,  and  becomes 
emphysematous  from  accumulation  of 
gases  in  the  tissues.  Blebs  contain- 
ing dark  brown  offensive  fluid  form 
on  the  surface,  and  the  softened 
cuticle  may  be  readily  detached  by 
merely  drawing  the  finger  over  the 
part.  The  blebs  met  with  in  gan- 
grenous parts  are  always  loose  and 
contain  coloured  fluid,  in  contrast  to 
those  formed  as  the  result  of  burns, 
friction,  or  galling,  which  are  tense 
-Dry^gangrene_  of  the  foot  and  and  usually  Contain  clcar  serum,  though 

this  may  be  blood-stained.  The  sur- 
face is  often  ecchymosed,  and  the  superficial  veins  may  be  clearly 
distinguishable  as  dark  lines.  The  skin  sloughs,  and  the  discharges 
are  horribly  offensive.  The  still  living  tissues  which  are  adjacent  to 
the  dead  are  swollen  from  inflammatory  exudate,  and  the  lymphatic 
vessels  and  glands  may  be  enlarged  and  inflamed. 


Fig.  i8. 


GANGRENE   OR   MORTIFICATION 


75 


The  constitutional  symptoms  of  gangrene  vary,  within  the 
widest  limits,  according  to  the  extent  and  scat  of  the  process,  the 
causes  inducing  it,  and  the  age  and  general  health  of  the  patient. 
In  many  cases  the  condition  is  a  purely  local  one,  and  there  are 
practically  no  general  symptoms,  e.g.  frost-bite ;  in  others,  e.g. 
gangrene  of  the  bowel  or  from  the  action  of  micro-organisms,  they 
may  be  of  the  severest  form  : — shock,  collapse,  nervous  prostration, 
and  the  supervention  of  typhoid  symptoms  ushering  in  a  fatal 
termination. 

Separation  of  gangrenous  parts. — Provided  that  the  cause 
inducing  gangrene  is  limited  in  its 
action,  and  that  the  seat  of  the  process 
is  not  such  as  to  quickly  cause  the 
patient's  death,  the  dead  parts  will  be 
gradually  separated  from  the  living  by 
suppurative  inflammation  occurring  at 
their  junction.  Some  forms  of  gan- 
grene, dependent  on  specific  causes, 
show  no  tendency  to  spontaneous  arrest, 
and  gradually  spread  until  the  patient 
succumbs.  The  process  of  separation 
is  as  follows  : — 

The  gangrenous  part,  acting  as  an 
irritant,  excites  inflammation  in  the 
adjacent  Hving  tissues.  Stasis  and 
thrombosis  occur  in  the  vessels,  and  the 
junction  of  the  dead  and  living  parts  is 
indicated  by  a  livid,  congested  hne — 
the  "  line  of  demarcation."  Leucocytes 
and  lymph  infiltrate  the  tissues,  and  at 
the  line  of  demarcation  suppuration 
gradually  effects  separation.  This  pro- 
cess of  ulceration  extends  through  the 
entire  thickness  of  the  part ;  but  as  the 
gangrene    extends    higher    up    in    the   Fig.  19. —  Gangrene  occurring  in  a 

f    •    ,     .y  •       ^1  1  „i.  .,^4.,,>^r-  young  man  as  the  result  of  injury'. 

superficial    than  m  the    deep    structures,  ^^e   dead   and   living   parts    are 

the  resulting  stump  would,  if  separation        -J-^,;! ^Lt^'donsU'set 

were  left  to  nature,  be  conical  (Fig.    18).  at  the  upper   part.      (Drawn   by 

,  ,  C.  H.  Freeman.) 

As    separation    progresses,    the   vessels 

are  obUterated  by  thrombosis,  so  that  bleeding  does  not  usually 
occur;  yet  it  may  be  profuse.  Tendons,  hgan.wnts,  bone,  etc.,. 
prove  very  resistant 


76  MANUAL  OF   SURGERY  chap. 

The  time  required  for  the  separation  of  gangrenous  tissues  varies 
much ;  thus,  in  gangrene  of  a  Umited  portion  of  skin,  the  slough 
may  separate  in  a  few  days,  while  many  weeks  would  be  required 
for  the  separation  of  a  hmb  were  it  left  to  the  unaided  powers  of 
nature. 

Repair  of  the  surface  left  after  complete  separation  is  brought 
about  by  granulation  and  cicatrisation. 

Prognosis  in  gangrene. — The  prognosis  as  regards  life  de- 
pends upon  the  extent,  situation,  and  cause  of  the  gangrene.  It  is 
always  serious  at  the  two  extremes  of  life,  and  in  the  debiHtated. 
Gangrene  dependent  upon  strictly  local  causes  of  a  non-infective 
nature,  and  not  attacking  parts  of  \ital  importance,  is  not  dangerous 
to  life  in  otherwise  healthy  patients,  provided  due  care  be  taken 
to  prevent  putrefaction,  or  reduce  it  to  a  minimum.  Gangrene 
dependent  on  some  constitutional  condition,  or  upon  some  specific 
poison,  is  always  of  extreme  gravity,  indicating  as  it  does  severe 
impairment  of  the  general  health,  or  the  presence  of  a  poison  of 
great  virulence. 

General  principles  of  treatment. — Although  each  form  of 
gangrene  requires  special  treatment,  certain  rules  are  applicable  to 
all.  Every  endeavour  must  be  made  to  remove  any  local  or 
constitutional  causes  upon  which  the  process  is  dependent,  and 
the  continuance  of  which  favour  its  spread.  The  general  health 
must  be  improved,  and  the  strength  maintained,  for  all  forms  of 
gangrene  are  productive  of  marked  ner\'ous  prostration  and  asthenia. 

Constitutional  treatment. — Depletion  must  be  avoided ;  easily 
digestible  food,  alcohol,  port  wine,  quinine,  preparations  of  bark, 
ammonia,  and  diffusible  stimulants  being  chiefly  relied  on.  Opium 
is  useful  in  all  forms  of  gangrene,  but  especially  in  the  diabetic ;  it 
allays  pain,  and,  by  inducing  sleep,  gives  tone  to  the  nervous  system, 
and  seems  to  have  some  direct  beneficial  action  in  arresting  the  pro- 
cess. It  should  be  given  in  grain  doses  ever}'  four  or  six  hours,  and 
the  dose  may  be  increased  as  tolerance  is  established.  Opium  must 
be  given  carefully,  especially  in  those  whose  kidneys  are  diseased, 
and  in  the  young.  The  bowels  should  be  kept  acting,  and  the  action 
of  the  kidneys  and  skin  encouraged,  ^^'hen  the  process  has  been 
arrested  and  fever  has  subsided,  separation  and  repair  may  be 
hastened  by  a  more  liberal  diet  and  tonics. 

Local  treatment. — The  occurrence  of  gangrene  as  the  result  of 
inflammation  may  sometimes  be  prevented  by  reheving  tension  by 
means  of  free  incisions.  Injurious  pressure  must  be  removed,  and 
the  circulation  favoured  by  elevation  and  warmth. 


V  GANGRENE  DUE  TO   PRESSURE  77 

In  dry  gangrene  all  that  is  necessary  is  to  wrap  the  part  up  in  a 
thick  layer  of  antiseptic  wool,  the  ulcerating  line  of  separation  being 
carefully  cleaned  and  treated  antiscptically. 

In  moist  gangrene  every  endeavour  must  be  made  to  prevent 
the  occurrence  of  putrefaction  and  to  relieve  tension  by  incisions. 
Warm  antiseptic  fomentations  are  most  useful,  or  the  limb  may  be 
enveloped  in  a  dressing  saturated  with  some  antis(;ptic  lotion,  or 
antiseptic  powders  may  be  dusted  over  it.  The  most  useful  anti- 
septics and  deodorants  are  solutions  of  carbolic  acid,  boracic  acid, 
or  chloride  of  zinc,  eucalyptus  and  carbolic  oil,  and  powdered 
charcoal,  boracic  acid,  or  iodoform.  Fomentations  should  be  made 
of  boracic  lint,  or  with  hot  boracic  solution. 

The  part  must  be  dressed  with  sufficient  frequency  to  ensure 
cleanliness,  but  not  too  often,  on  account  of  the  pain  and  distress 
to  the  patient.  The  line  of  separation  must  be  separately  dressed 
with  antiseptic  lotions.  Sloughs  should  as  a  rule  be  left  to  separate 
spontaneously ;  but  should  their  removal  be  deemed  advisable,  in 
order  to  diminish  the  amount  of  putrefying  matter,  they  may  be  cut 
away  with  scissors,  care  being  taken  that  still  living  tissue  is  not 
damaged. 

Amputation. — In  gangrene  of  the  extremities  the  question  of 
amputation  naturally  arises.  In  acute  spreading  gangrene  of  an 
infective  nature  immediate  operation  is  essential,  since  no  limitation 
of  the  process  can  occur. 

In  gangrene  dependent  on  local  causes,  or  on  arterial  obstruc- 
tion, it  is  wiser  to  wait  until  the  line  of  separation  is  clearly  indicated, 
so  that  amputation  is  performed  through  tissues  of  sufficient  vitality. 
In  such  cases  it  is  impossible  to  say  how  much  of  the  limb  will 
perish.  Moreover,  it  is  not  only  necessary  that  amputation  should 
be  performed  through  still  living  parts,  but  their  vitality  must  be 
sufficiently  great  to  allow  of  healing,  otherwise  this  may  not  occur, 
and  sloughing  or  gangrene  of  the  flaps  may  result. 

GANGRENE  DUE  TO  PRESSURE BED-SORES 

Etiology. — Bed-sores  are  unhealthy  ulcers  due  to  gangrene  of 
the  superficial  parts  as  the  result  of  prolonged  pressure.  In  some 
cases  the  gangrene  is  preceded  by  inflammation,  in  others  it  occurs 
directly  from  exsanguination.  Bed-sores  are  especially  met  with  in 
the  aged,  enfeebled,  and  cachectic,  and  in  those  confined  to  bed 
for  a  long  time  in  consequence  of  some  chronic  disease  or  severe 
injury.      Paralysed  parts  are   very  subject    to   bed-sore,   partly  on 


78  MANUAL  OF  SURGERY  chap. 

account  of  their  lowered  vitality.  Spinal  and  head  injuries,  associ- 
ated with  nervous  lesions,  sometimes  occasion  deep,  rapidly-spread- 
ing, gangrenous  areas — acute  bed-sores.  These  are  probably  due  to 
interference  with  the  innervation  of  the  parts,  in  addition  to  the 
usual  local  causes. 

Bad  nursing  is  too  frequently  responsible  for  the  occurrence  of 
bed-sores ;  the  accumulation  of  dirt  and  moisture  (e.g.  urine),  infre- 
quent changing  of  the  draw-sheets,  and  improper  bedding  being 
important  avoidable  causes. 

Similar  sores  may  be  caused  by  ill-fitting  surgical  appliances  and 
splints. 

Seat  and  appearances. — Those  parts  most  subjected  to  pressure 
are  the  favourite  situations  of  bed-sores  ;  they  usually  form  on  the 
sacrum,  buttocks,  trochanters,  malleoli,  and  heels,  more  rarely  about 
the  scapular  regions,  and  on  the  elbows  and  knees.  Before  a  sore 
has  actually  formed  the  skin  becomes  red  and  somewhat  roughened, 
and  is  very  tender,  except  in  paralysed  and  anaesthetic  parts.  If 
these  indications  are  neglected — and  sometimes  even  in  spite  of 
treatment — a  small  bleb  forms  on  the  surface,  gangrene  of  the  skin 
quickly  follows,  and  is  surrounded  by  a  zone  of  inflammation.  In 
bad  cases,  especially  in  the  acute  sores  met  with  in  spinal  injury, 
the  gangrene  eats  deeply  into  the  tissues,  exposing  and  destroying 
the  muscles  and  bones.  The  dead  and  sloughy  tissues  slowly  sepa- 
rate, leaving  an  unhealthy  ulcer,  which  may  gradually  extend  in  area 
and  depth,  or  exhibit  a  feeble  attempt  at  granulation.  In  most  cases 
pain  and  discomfort  are  complained  of  at  an  early  period,  and  be- 
come more  severe  when  gangrene  has  actually  occurred  ;  but  in 
anaesthetic  parts,  or  if  the  patient  be  very  ill,  no  such  complaint 
may  be  made. 

Prognosis. — The  prognosis  in  cases  of  bed-sore  depends 
upon  the  state  of  the  patient.  If  the  condition  which  confines 
him  to  bed  is  one  inducing  serious  general  disturbance,  and  if 
he  shows  no  signs  of  improvement,  it  can  hardly  be  expected  that 
the  bed-sores  will  heal,  although  with  careful  treatment  further 
damage  may  be  prevented.  Bed-sores  in  paralysed  parts  are  very 
intractable. 

If  the  patient  recovers  his  general  health,  these  sores  rapidly 
improve.  Occasionally  they  prove  fatal  from  exhaustion,  or  the 
supervention  of  pyaemia.  Acute  bed-sores,  in  association  with  spinal 
injury,  nearly  always  indicate  a  fatal  termination. 

Treatment. — Preventive. — The  formation  of  bed-sores  maybe 
prevented  in  most  cases  by  careful   nursing,  and  the  avoidance  of 


V  GANGRENE   FROM   ARTERIAL   DISEASE  79 

those  causes — often  trivial  in  themselves — which  have  been  shown 
to  produce  them.  The  patient  should  be  placed  on  a  comfortable 
mattress,  with  a  clean,  soft  draw-sheet  immediately  underneath  him, 
which  should  be  changed  frequently.  On  no  account  should  he  lie 
on  a  feather  bed  or  on  a  blanket ;  the  former  rucks,  the  latter  is 
rough  and  irritating.  The  use  of  a  water-bed  or  water-pillow  is  the 
safest  preventive  measure  in  very  feeble  persons.  Absolute  cleanli- 
ness and  dryness  are  essential.  The  back  and  other  parts  liable  to 
pressure  should  be  examined  once  or  twice  daily,  and,  after  being 
washed  and  dried,  dusted  with  finely  powdered  boracic  acid.  If 
the  skin  becomes  tender  or  red,  it  should  be  rubbed  twice  daily  with 
spirit  or  eau-de-cologne,  or  painted  with  collodion  ;  or  it  may  be 
gently  rubbed  with  a  mixture  of  equal  parts  of  balsam  of  Peru  and 
resin  ointment.  Pressure  should  be  relieved  by  frequent  change  in 
the  patient's  position,  and  by  the  employment  of  circular  air-  or  water- 
cushions. 

Curative. — All  pressure  must  immediately  be  taken  off  the  seat 
of  ulceration.  In  bad  bed-sores  on  the  buttocks  or  sacrum  I  have 
had  excellent  results  from  placing  the  patient  on  a  canvas  hammock, 
with  a  hole  of  suitable  size  cut  in  it  beneath  the  site  of  the  sore ; 
this  effectually  relieves  all  pressure,  and  allows  the  necessary  dress- 
ings to  be  applied  without  troubling  the  patient.  If  there  is  merely 
vesication  and  separation  of  the  cuticle,  the  part  should  be  protected 
by  covering  it  with  a  thin  layer  of  antiseptic  wool  and  collodion,  or 
by  the  application  of  boracic  ointment. 

When  sloughing  is  fully  established,  warm  irrigation  with  boracic 
acid  is  most  useful,  or  the  part  may  be  fomented  to  encourage  sepa- 
ration of  the  sloughs.  As  soon  as  granulation  sets  in,  the  wound 
must  be  treated  like  an  ordinary  healing  ulcer. 

Constitutionally  every  effort  must  be  made,  by  good  feeding 
and  stimulants,  to  improve  the  general  health.  Opium  is  very 
useful. 


GANGRENE    FROM    ARTERIAL    DISEASE SENILE    GANGRENE 

Seat. — Senile  gangrene  attacks  peripheral  parts  in  which  the 
circulation  is  naturally  feeble.  Most  commonly  it  is  seen  in  the 
toes  or  fingers ;  but  the  margins  of  the  ears  and  alae  of  the  nose  are 
not  rarely  affected.  The  gangrene  may  be  quite  limited  in  extent, 
or  may  attack  many  toes  or  fingers  and  gradually  extend  up  the 
limb. 

Causes. — Atheroma  and  primary  calcification  of  the  arteries, 


So  MANUAL   OF   SURGERY  chap. 

combined  with  cardiac  weakness  and  the  general  lowered  vitality  of 
the  tissues  through  imperfect  nutrition,  are  the  essential  causes  of 
senile  gangrene.  Its  onset  is  usually  determined  by  thrombosis  in 
the  diseased  vessels,  or  by  some  trivial  injury  or  inflammation,  the 
nutrition  of  the  tissues  being  at  such  a  low  ebb  that  bare  existence 
of  them  is  alone  possible,  and  any  source  of  irritation,  however 
slight,  results  in  gangrene. 

Signs. — Certain  symptoms  indicative  of  imipaired  circulation  are 
usually  complained  of  before  gangrene  manifests  itself,  and  their 
recognition  should  lead  to  the  adoption  of  preventive  measures. 
There  is  a  feeling  of  heaviness  in  the  Hmb  with  frequent  cramp, 
tingling  or  itching,  and  numbness  with  per\-erted  sensation,  alter- 
nating with  or  accompanied  by  severe  aching  pain.  The  extremity 
is  cold,  blue,  and  cyanosed,  and  there  may  be  slight  swelling,  espe- 
cially at  night.  All  the  signs  are  more  marked  in  cold  weather. 
Pulsation  in  the  arteries  is  ver}'  faint,  or  may  be  indistinguishable. 
In  the  presence  of  a  wound  or  slight  inflammation,  a  small  slough 
may  form ;  this  dries  and  shrivels,  and  the  gangrene  spreads  slowly 
but  surely,  and  is  surrounded  by  a  painful  inflamed  area,  which  in 
its  turn  dies.  In  other  cases  a  small  ulcer  may  be  the  starting-point 
of  the  process  ;  or  it  may  begin,  in  the  absence  of  injur}-,  as  a  purple 
or  dark  spot  surrounded  by  an  inflammatory  zone.  The  gangrene 
is  of  the  dry  variety ;  the  dead  parts,  losing  water  by  evaporation, 
shrivel  up,  and  resemble  the  tissues  of  a  mummy.  The  characters 
have  been  already  described  (p.  74).  When  m.ore  healthy  tissues 
are  reached,  a  line  of  separation  forms,  and  the  dead  part  may 
be  cast  off.  Sometimes,  even  after  the  process  has  apparently 
ceased,  the  gangrene  advances,  and  a  second  line  of  demarcation 
forms. 

Constitutional  symptoms  may  be  entirely  absent,  but  if  the 
gangrene  is  extensive,  or  there  is  much  pain,  the  general  health 
suffers.  The  patient  gradually  loses  health  and  strength,  his  nights 
are  broken  and  sleepless  on  account  of  the  pain  he  suffers,  and  he 
may  succumb  from  exhaustion.  Sometimes  there  is  fever  of  the 
asthenic  type,  especially  if  there  is  inflammation  and  putrefaction  at 
the  line  of  separation. 

Prognosis. — The  prognosis  is  always  grave,  as  the  occurrence  of 
senile  gangrene  is  dependent  on  arterial  disease  and  general  lower- 
ing of  vitality.  The  gravity  depends  on  the  extent  and  rapidity  of 
the  process  and  upon  the  general  state  of  the  patient.  Separation 
of  the  gangrenous  part,  if  left  to  nature,  may  take  weeks  or  months 
according  to  its  extent. 


V  GANGRRNr:   FROM   ARTERIAL  DISEASE  8i 

Treatment. — General. — Depletory  measures  arc  of  course 
contra-indicated.  The  bowels,  kidneys,  and  skin  should  be  kept 
acting  freely  by  the  use  of  appropriate  remedies.  The  food  must  be 
generous  in  quantity  and  of  an  easily  digestible  nature  ;  it  should 
be  given  in  small  quantities  at  frequent  intervals,  so  as  not  to  over- 
tax the  digestive  powers.  Stout,  port  wine,  and  other  alcoholic 
and  diffusible  stimulants  must  be  given  to  encourage  the  action  of 
the  heart ;  the  amount  being  regulated  by  the  state  of  the  pulse. 
Small  doses  of  strychnine  should  be  prescribed ;  bark  and  the 
mineral  acids,  cod-liver  oil  and  tonics  are  useful  if  the  patient  can 
digest  them.  ( 

No  drug  is  so  valuable  as  opium,  and  it  should  be  given  in 
gradually  increasing  doses,  beginning  with  one  grain  every  six 
hours.  Opium  gives  tone  to  the  nervous  system  by  the  relief  of 
pain  and  by  inducing  sleep ;  the  improvement  it  effects  is  often 
very  marked. 

Local. — When  gangrene  is  threatened,  the  part  should  be 
wTapped  in  cotton  wadding  and  kept  in  an  elevated  position,  free 
from  all  sources  of  irritation.  Gentle  friction  and  tepid  bathing 
may  increase  the  circulation. 

When  gangrene  has  actually  occurred,  the  dead  parts  must  be 
kept  dry  to  avoid  putrefaction,  and  should  be  wrapped  up  in  anti- 
septic wool  dusted  with  iodoform  or  boracic  powder.  The  dressing 
should  not  be  removed  unnecessarily,  nor  should  the  part  be  ex- 
posed to  the  air.  The  line  of  separation  must  be  antiseptically 
dressed  and  putrefaction  prevented ;  it  may  be  lightly  dusted  with 
iodoform  and  dressed  with  iodo-vaseline  or  boracic  ointment ;  wet 
dressings  are  better  avoided.  The  whole  limb  must  be  elevated 
and  enveloped  in  flannel  or  wadding.    • 

As  soon  as  the  true  line  of  separation  has  formed,  amputation 
should  be  performed  before  the  patient's  strength  is  exhausted. 
This  is  always  a  serious  step  in  view  of  the  general  and  local  con- 
ditions-upon  which  the  gangrene  is  dependent;  the  advisability 
of  the  operation  and  its  seat  must  be  determined  on  the  merits 
of  each  case.  If  amputation  is  performed  just  above  the 
line  of  separation,  there  is  a  risk  of  sloughing  of  the  flaps,  or 
of  failure  in  the  healing  process,  since  the  vitality  of  the 
tissues  is  much  diminished  ;  in  quite  limited  gangrene,  however, 
when  there  is  evident  pulsation  in  the  vessels  above,  this 
operation  may  be  undertaken.  In  other  cases  it  is  wiser  to 
amputate  at  a  distance.  Although  such  a  procedure  entails  more 
shock,  this  is  counter-balanced  by  the  fact  that  the  parts  operated 
VOL.  I  G 


82  MANUAL   OF   SURGERY  chap. 

on  are  more   healthy,  and  there  is   a  better  prospect   of  speedy 
cure. 

In  gangrene  of  the  upper  limb,  amputation  may  usually  be  per- 
formed in  the  middle  of  the  arm  ;  in  the  lower  hmb,  the  knee,  or 
lower  third  of  the  thigh  are  the  points  of  election.  In  deciding  on 
the  seat  of  amputation,  it  should  be  borne  in  mind  that  calcifica- 
tion of  the  arteries  is  most  extensive,  and  produces  most  serious 
effects  in  the  smaller  vessels,  viz.  those  below  the  knee  and  in 
the  forearm,  and  if  amputation  is  performed  through  more  healthy 
vessels,  healing  will  occur  more  readily.  The  operation,  when 
decided  upon,  should  not  be  delayed,  and  should  be  done  bloodlessly, 
with  the  strictest  antiseptic  precautions.  The  flaps  should  not  be 
redundant,  nor  contain  an  unnecessary  amount  of  muscle ;  above 
all,  they  must  not  be  scored  or  injured  by  the  knife.  The  circular 
method  of  operation,  giving  as  it  does  the  least  area  of  raw  surface, 
is  the  best.  The  diseased  vessels  must  be  carefully  secured  with 
carbolised  silk,  and  the  dressings  should,  unless  fever  or  other 
signs  contra-indicate,  be  left  untouched  for  a  week  or  ten  days. 
Gangrene  of  the  flaps,  secondary  haemorrhage,  and  shock  are  the 
chief  dangers. 

GANGRENES    DUE    TO    ARTERIAL    SP.AlSM SYMMETRICAL 

GANGRENE RAYNAUD'S    DISEASE 

Raynaud's  disease  is  dependent  on  spasm  of  the  small  arteries, 
probably  due  to  central  cord  changes.  In  some  cases  at  least 
it  appears  probable  that  the  condition  is  the  result  of  peri- 
pheral neuritis.  The  spasm  induces  retardation  and  arrest  of 
the  circulation  with  venous  congestion.  These  attacks  are  of 
short  duration,  but  if  frequently  repeated  may  cause  gangrene. 
The  disease  is  usually  met  with  in  children,  or  in  women 
between  fifteen  and  thirty  years  of  age ;  more  rarely  it  afiects 
males. 

Cold,  mental  perturbation,  and  local  injury  may  excite  an 
attack. 

Signs. — The  signs  var}-  in  intensity  _from  a  mere  sensation  of 
numbness  to  complete  gangrene  of  the  fingers.  The  following 
stages  or  degrees  of  intensity  are  recognised  : — 

(a)  Local  syncope. — The  tip  of  the  finger  (or  fingers),  sometimes 
in  an  apparently  healthy  patient  and  without  evident 
cause,  becomes  cold,  bloodless,  and  of  a  dead  white 
colour;    it    is    anaesthetic     and    movement    is    sometimes 


(■.a\(;ri.n'i;s  klic  io  arterial  spasm 


83 


lost.  The  attack  may  last  minutes  or  hours,  and  usually 
recurs  at  intervals. 
(d)  Local  asphyxia. — The  signs  of  impeded  circulation  are 
more  marked.  The  skin  assumes  a  livid  hue,  or  may 
appear  as  if  ink-stained,  the  area  of  cyanosis*  being  fringed 
by  a  vermilion  margin.  The  superficial  veins  are  often 
clearly  marked  as  livid  lines.  Motion  is  diminished  or 
lost,  and  there  is  superficial  anaesthesia  \vith  deep-seated 
burning  pain.  The  pulse  at  the  wrist  is  often  small  and 
feeble.  An  attack  may,  as  in  the  previous  state,  last 
minutes  or  hours,  and  recurs  at  intervals  ;  as  it  passes 
off,  the  finger  regains  its  normal  colour  and  is  the  seat  of 
tingling  or  stinging  pain. 
{t')  Symmetrical  gangrene  is  the  outcome  of  repeated  attacks  of 
the  above  conditions. 
The  parts  about  to 
become  gangrenous 
exhibit  the  appear- 
ances met  with  in 
local  asphyxia  ;  small 
vesicles  filled  with 
sero-pus  form  at  the 
finger  tips  ;  these 
burst,  leaving  minute 
sores.  Temporary  im- 
provement may  now 
occur,  only  to  be 
followed  by  fresh 
ulceration.  The  finger' ends  usually  taper  and  mummify, 
and  the  nails  turn  black.  Sometimes  the  skin  may  slough 
and  the  nails  fall  off,  the  raw  patches  healing  by  granula- 
tion or  remaining  open. 
In  other  cases  the  gangrene  is  more  rapid,  and  there  is  no 
temporary  improvement.  Dry  gangrene  rapidly  occurs  and  the 
dead  part  is  separated  from  the  living  by  a  line  of  ulceration.  The 
extent  varies ;  all  the  fingers  of  both  hands  and  part  of  the  hands 
may  die;  sometimes  the  feet  suffer  simultaneously  (Fig.  20). 

As  a  rule  there  is  no  impairment  of  the  general  health  unless 
constant  pain  has  produced  sleeplessness.  Very  often  there  is  a 
distinct  periodicity  in  the  disease,  the  symptoms  disappearing  and 
recurring  at  intervals.     It  may  extend  over  many  months. 

Diagnosis. — When    gangrene  is  established,  the  diagnosis  is 


Fig.  20. — Symimetrical  gangrene  of  the  great  toes 
from  a  young  woman  who  was  the  subject  of 
Raynaud's  disease.  (Drawn  by  C.  H.  Free- 
man.) 


84  MANUAL  OF  SURGERY  chap. 

easy.  Local  syncope  or  asphyxia  may  be  mistaken  for  chilblains. 
The  periodicity,  duration,  and  symmetrical  distribution  of  the 
lesions,  coupled  with  their  occurrence  at  all  times  of  the  year,  are 
the  main  diagnostic  points.  Simple  senile  gangrene  is  not  likely 
to  be  mistaken  for  Raynaud's  disease,  the  age  of  the  patient  alone 
being  sufficient  to  prevent  such  a  mistake. 

Treatment. — Warmth  and  gentle  friction  should  be  applied 
during  an  attack  of  arterial  spasm,  and  opiates  may  be  necessary  to 
relieve  pain.  Electricity  has  been  found  the  most  useful  remedy 
among  the  many  tried.  The  hand  and  one  of  the  electrodes 
should  be  placed  in  a  basin  of  hot  salt  solution  and  the  other 
electrode  higher  up  on  the  arm ;  the  current  should  be  as  strong  as 
the  patient  can  bear  it  and  should  be  frequently  interrupted. 

Iron,  quinine,  and  good  food  should  be  given. 

When  gangrene  has  occurred,  the  sloughs  should  be  left  to 
separate,  and  if  its  extent  requires  amputation,  this  should  be  per- 
formed when  the  line  of  separation  has  fully  formed. 


GANGRENE  FROM  ERGOTISM 

Ergot  gangrene  was  at  one  time  more  or  less  common  in 
France ;  it  is  now  rarely  met  with.  It  occurred  only  among  the 
very  poorest  peasants,  whose  food  mainly  consisted  of  rye  bread,  and 
who  lived  amid  privations  and  hardships  that  were  no  doubt 
powerful  predisposing  causes.  It  was  more  common  in  men  than 
women,  and  sometimes  occurred  in  epidemics.  The  feet  were 
more  often  affected  than  the  hands,  and  the  disease  was  sometimes 
bilateral  and  varied  in  extent.  The  gangrene  was  of  the  dry 
variety,  closely  resembling  the  senile  form.  Constitutional  symp- 
toms and  even  death  were  sometimes  induced  by  the  toxic 
properties  of  ergot. 

Amputation,  when  the  line  of  separation  had  formed,  was  the  only 
treatment. 

GANGRENE    DUE   TO    DIATHETIC    STATES DIABETIC    GANGRENE 

Diabetic  patients  are  peculiarly  susceptible  to  low  forms  of 
inflammation  terminating  in  sloughing  or  gangrene,  and  often 
resulting  from  the  most  trivial  injury,  such  as  the  application  of  a 
blister. 

Diabetes  not  only  exhausts  the  patient  and  impairs  general 
nutrition,  but  is  frequently  associated  with  arterial  degeneration  and 


V  GANGRENE   DUE   TO   DIATHETIC   STATES         85 

peripheral  neuritis,  and  it  has  been  already  shown  that  these  are  in 
themselves  powerful  factors  in  the  production  of  gangrene.  It  must 
be  remembered  that  the  presence  of  sugar  in  the  urine  is  not 
necessarily  diagnostic  of  diabetic  gangrene.  Transient  glycosuria 
has  often  been  noted,  apparently  as  the  outcome  of  any  gangrenous 
process.  The  course  and  rapidity  of  the  gangrenous  process  varies, 
and  some  authorities  recognise  three  forms  coinciding  with  the  most 
prominent  causative  factors.  Inflammatory  gangrene  of  the  moist 
variety  runs  an  acute  course  characterised  by  extensive  ulceration 
and  sloughing,  and  may  result  from  a  slight  injury  or  trivial 
inflammation. 

When  arterial  degeneration  is  responsible  for  the  necrosis,  it 
assumes  all  the  characters  of  senile  gangrene,  is  accompanied  by 
great  pain,  and  runs  a  rather  rapid  course.  The  neuritic  form,  on 
the  other  hand,  is  painless,  and  progresses  slowly,  and  may  begin 
as  a  perforating  ulcer. 

Diabetic  gangrene  often  begins  as  a  bleb  containing  dark  brown 
fluid,  surrounded  by  an  inflammatory  zone  ;  the  neighbouring  tissues 
participating  in  the  inflammatory  condition  gradually  perish,  and 
the  gangrene  spreads. 

Prognosis. — The  prognosis  is  very  grave,  especially  in  rapidly- 
spreading  cases,  in  the  aged,  and  when  the  amount  of  sugar 
passed  is  large.  Death  may  occur  from  exhaustion  or  diabetic 
coma. 

Treatment. — As  soon  as  the  line  of  separation  has  formed, 
amputation  must  be  resorted  to,  if  the  condition  of  the  patient  will 
admit.  In  the  inflammatory,  rapidly-spreading  gangrene,  a  line  of 
separation  may  never  form,  the  patient  quickly  succumbing  from 
exhaustion  or  acetonaemia.  No  doubt  diabetics  are  not  good 
patients  for  surgical  operations,  but  recent  work  has  shown  that  the 
dangers  have  been  exaggerated.  The  strictest  antiseptic  precau- 
tions must  be  adopted,  and  the  patient  got  well  under  treatment  by 
opium  and  appropriate  dietary.  After  removal  of  the  gangrenous 
part  the  amount  of  sugar  passed  materially  diminishes,  although 
this  improvement  may  not  be  permanent. 

The  point  at  which  amputation  should  be  performed  varies 
with  circumstances,  and  is  a  matter  of  importance.  If  there  is 
evidence  of  marked  arterial  disease,  amputation  should  be  per- 
formed high  up,  as  in  cases  of  senile  gangrene ;  but  if  the  progress 
of  the  case  is  slow  and  unaccompanied  by  pain,  neuritis  being  there- 
fore the  presumable  cause,  the  limb  may  be  removed  just  above  the 
line  of  separation. 


86  MANUAL   OF   SURGERY  chap,  v 


GANGRENE    DUE    TO    MICRO-ORGANISMS 

Certain  micro-organisms  are  capable  of  inducing  severe  inflam- 
mation, resulting  in  sloughing  or  gangrene.  These  forms  are  fully 
discussed  with  the  infective  processes ;  they  include  boil,  carbuncle, 
malignant  pustule,  cancrum  oris,  hospital  gangrene,  phagedaena,  and 
acute  emphysematous  gangrene  (see  chap.  vii.  p.  102). 


CHAPTER    VI 

Bacteriology  in  Relation  to  Surgery 

The  science  of  bacteriology  may  be  said  to  date  from  the  investiga- 
tions of  Pasteur  (1857)  into  the  causes  of  fermentation,  a  process 
long  recognised  as  presenting  a  very  close  analogy  to  putrefaction 
and  the  infectious  diseases.  Pasteur  showed  that  each  kind  of 
fermentation  was  dependent  upon  the  presence  of  specific  micro- 
organisms, and  although  some  denied  their  influence,  attributing 
their  undoubted  presence  to  accidental  contamination,  the  germ- 
theory  receives  at  present  universal  support. 

Some  organisms  act  by  inducing,  as  the  direct  result  of  their 
own  metabolic  activity,  chemical  changes  in  tiie  fermenting  matter 
(organised  ferments) ;  in  the  case  of  others,  the  changes  are  brought 
about  by  means  of  unorganised  ferments  of  a  complex  albuminoid 
nature,  secreted  by  the  organisms ;  such  ferments  excite  the 
resulting  chemical  changes  without  themselves  undergoing  any 
alteration.  Ptyalin  and  pepsin  are  examples  of  unorganised 
ferments  in  the  body. 

The  clinical  course  of  contagious  and  infectious  disea'fees 
suggests  the  occurrence  of  processes  analogous  to  those  demon- 
strated as  taking  place  in  fermentation.  The  science  of  bacteri- 
ology has  for  its  aims  the  discovery  of  organisms  capable  of 
exciting  disease,  the  study  of  their  life-history  and  mode  of  action, 
and  of  the  conditions  favourable  or  inimical  to  their  growth  and 
development. 

There  are  many  infectious  diseases  in  which,  at  present,  no 
definite  organism  has  been  found  ;  but  in  other  cases  organisms 
have  been  isolated  and  proved  by  demonstration  to  be  the  con- 
tagium  vivum.  l>y  analogy  we  may  fairly  assume  that  such  causa- 
tive  factors   will   be   proved    to    exist    in   all    infectious    processes. 


88  MANUAL  OF  SURGERY  chap. 

Before  we  can  be  certain  that  any  organism  stands  to  a  given 
disease  in  the  relation  of  its  cause,  and  not  as  a  mere  accident  or 
association,  certain  conditions  must  be  fulfilled  (Koch's  postu- 
lates)— 

(i)  The  organism  must  be  constantly  present  in  the  tissues  or 
fluids  of  the  diseased  animal. 

(2)  It  must  be  isolated,  and  pure  cultivations  of  it  obtained. 

(3)  The  disease  must  be  reproduced  in  animals  by  inoculation 

with  the  organisms  from  such  cultivations. 

(4)  The  same  organism  must  be  present  in  the  tissues  or  fluids 

of  the  inoculated  animals. 
Micro-organisms  belong  to  the  lowest  class  of  fungi,   and   are 
divided  into  three  groups — 

(i)  The  bacteria  or  schizomycetes. 

(2)  The  yeasts  or  blastomycetes. 

(3)  The  moulds  or  hyphomycetes. 

The  bacteria  are  by  far  the  most  important,  since  to  this  class 
belong,  with  few  exceptions,  those  micro-organisms  shown  to  be  the 
causative  elements  in  infectious  diseases.  The  yeasts  and  moulds 
will  not  be  considered  here. 


THE    BACTERIA,    SCHIZOMYCETES,    OR    FISSION-FUNGI 

Structure  and  physical  characters. — The  bacteria  are 
unicellular  vegetable  organisms  devoid  of  chlorophyll ;  they  belong 
to  the  lowest  class  of  fungi,  and  are  composed  of  delicate  proto- 
plasmic material — mycoprotein — enclosed  by  a  protective  sheath 
of  the  nature  of  cellulose.  The  protoplasm  is  often  granular,  and 
contains  nuclear  chromatine,  but  no  definite  nucleus  has  been 
demonstrated.  In  some  cases  the  outer  part  of  the  investing 
membrane  is  gelatinous,  the  organism  appearing  to  be  surrounded 
with  hyaline  material;  this  material  may  bind  together  numerous 
microbes  into  zoogloea  masses. 

Most  organisms  are  colourless,  but  some  contain  pigment,  which 
is  present  in  the  protoplasm,  in  the  investing  membrane,  or  both, 
and  which  readily  diffuses  in  nutrient  media,  wherein  the  organism 
may  be  placed  for  purposes  of  cultivation,  and  thus  forms  an  aid  to 
diagnosis. 

Some  organisms  {e.g.  bacillus  tuberculosis)  are  motionless,  others 
are  motile.  The  latter  variety  possess  flagella,  developed  usually  at 
one  or  both  ends,  and  sometimes  laterally,  as  in  the  typhoid  bacillus. 
The  number  of  flagella  varies ;  sometimes  there  is  only  one,  but 


VI  BACTERIA  89 

there  may  be  one  or  more  at  each  end.  These  flagella,  which  are 
developed  from  the  investing  membrane  and  protoplasm,  are,  on 
account  of  their  extreme  tenuity,  diffi- 
cult of  demonstration. 

Some  of  the  organisms  are  true 
parasites,  i.e.  they  live  in  and  at  the 
expense  of  a  host ;  others,  known  as 
saprophytes  or  carrion-fungi,  live  only 
on  dead  matter.  The  former  are 
known  as  pathogenic,  the  latter  as  non- 
pathogenic organisms.  Their  effects 
and  mutual  relations  will  be  more  fully  ^ 
discussed  later  on. 

Classification.  —  For  practical 
purposes  bacteria  are  divided  accord- 
ing   to    their    shape    into   micrococci,  Fig.  21. 

1        -ii-  J        •••>■,  T\-phoid  bacilli  showing  flagella- 

bacilli,  and  spirilla.  '^ 

Microeoeei  are  the  smallest  microbes  kno\vn.  They  are  round 
or  oval  in  shape,  and  motionless.  They  germinate  by  fission  only, 
never  by  spores,  and  this  process  of  fission  may  give  rise  to  a  varia- 
tion in  grouping.  Thus  they  may  be  found  as  single  cocci,  the 
individual  organisms  having  no  definite  relation  to  each  other ;  or 
when  a  coccus  di\'ides,  the  resulting  cocci  may  remain  close 
together,  forming  a  pair  (diplococcus,  Fig.  34,  p.  156);  these  again 
dividing  in  the  same  plane,  chains  or  chaplets  result  (streptococcus. 
Fig.  10,  p.  41).  Organisms  irregularly  grouped  together,  as  in 
zoogloea  masses,  are  known  as  staphylococci  (Fig.  9,  p.  40).  If  an 
organism  di\ides,  and  the  resulting  pair  divide  again  in  a  plane  at 
right  angles  to  the  first,  a  group  of  four  is  formed  (tetrad) ;  the 
process  being  repeated  gives  rise  to  a  group  of  eight  (sarcina),  and 
so  on.  This  grouping  is  not  a  mere  matter  of  accident,  but  is 
characteristic  of  individual  forms. 

The  micrococci  which  are  known  to  possess  pathogenic  pro- 
perties are  those  of  suppuration,  \-iz.  staphylococcus  pyogenes  aureus 
and  albus,  streptococcus  pyogenes,  etc.  (see  p.  40).  The  M.  ureae 
excites  putrefactive  changes  in  urine ;  sarcina  ventriculi  is  met  with 
in  the  vomit  from  cases  of  pyloric  obstruction. 

Baeilli  are  straight,  or  but  slightly  curved,  elongated,  rod-shaped 
organisms.  '  They  differ  considerably  in  size,  and  many  of  them,  being 
armed  with  flagella,  exhibit  constant  oscillatory  or  rotatory  movements 
(Fig.  21).  Some  bacilli  multiply  by  fission  only,  others  by  fission 
and  by  spores,  the  latter  being  very  resistant  to  injurious  influences. 


90 


MANUAL  OF   SURGERY 


CHAP. 


Fig.  22. — Spirilla  and  red  blcK>d  cells. 


Bacilli  may  form  zooglcea  masses,  or,  dividing  transversely,  may 
remain  united  by  gelatinous  material,  and  form  long  chains ;  in 
other  cases  they  are  not  definitely  grouped. 

Bacilli  are  found  in  tubercle,  syphilis,  leprosy,  rhinoscleroma, 
anthrax,  glanders,  diphtheria,  influenza,  typhoid,  tetanus,  noma, 
malignant  oedema,  plague,  and  septicaemia.  The  B.  coli  communis 
is  constantly  present  in  the  intestine,  and  has  pathogenic  properties. 
The  B.  lactis  aerogenes,  bacillus  pyocyaneus,  and  proteus  vulgaris 
are  occasionally  met  with. 

Spirilla  are  motile  organisms  occurring  either  as  long,  closely- 
wound  flexible  spiral  cells,  or  are 
shorter,  more  open  and  stiff.  They 
germinate  by  spores. 

Spirilla    are    met    with    in    re- 
lapsing fever  and  cholera. 

Life  -  history  of  micro- 
organisms.— Habitat.  —  Bacteria 
are  abundantly  present  in  nearly 
all  things  surrounding  us ;  but, 
while  thus  universal  in  their  dis- 
tribution, they,  like  all  other  living  things,  grow  better  and 
multiply  more  abundantly  in  some  media  than  in  others,  and 
under  certain  inimical  conditions  die,  or  fail  to  develop,  although 
retaining  the  power  to  do  so.  Bacterial  growth  is  specially  prolific 
in  organic  matter  with  warm  and  moist  surroundings.  Air,  especi- 
ally if  moist  or  dust-laden,  and  in  the  neighbourhood  of  defective 
sanitar)'  arrangements  or  of  infective  centres,  e.g.  hospitals,  is  very 
rich  in  microbes.  Dry  air  is  nearly  sterile,  since  all  organisms 
require  moisture.  The  surface  soil  is  rich  in  bacteria,  especially 
bacilli,  but  deeper  down  they  decrease  in  number,  and  at  about  one 
metre  none  are  found  unless  carried  there  by  percolation  of  surface 
water.  Deep  spring  water  is  almost  sterile,  but  ordinar}-  water  is 
rich  in  bacteria,  all  of  which  may  readily  be  killed  by  boiling.  The 
surface  of  tne  skin  and  mucous  cavities  are  favourable  sites  for 
bacteria,  but  in  the  case  of  the  skin  they  cannot,  in  the  absence  of 
a  wound,  gain  entrance  to  the  body.  Bacteria  may  possibly  pass 
throu2;h  the  mucous  membranes  in  small  numbers,  but  are  usually 
soon  destroyed. 

Conditions  essential  for  life  and  growth. — Like  other  living 
things,  bacteria  require  nutriment  and  favourable  surroundings;  but 
even  if  the  conditions  are  not  favourable  to  development,  the 
organisms   may   remain   linng,    though   dormant,    and    capable    of 


VI  BACTERIA  91 

growing  and  multiplying  when    the  inimical  conditions  no  longer 
exist. 

Most  bacteria  of  interest  to  the  surgeon  are  pathogenic,  i.e.  they 
are  true  parasites  and  find  in  the  body  of  the  host  pabulum  suitable 
to  their  requirements.  Parasitic  microbes  are  obligate  ox  facultative  ; 
the  former  cannot  grow  outside  a  host,  the  latter,  although  usually 
leading  a  non-parasitic  existence,  are  capable  of  acting  as  true 
parasites. 

The  non-pathogenic  bacteria  are  saprophytes  or  carrion-fungi, 
obligate  or  facultative ;  they  can  only  subsist  on  dead  matter,  and  if 
taken  into  the  body,  speedily  die.  In  many  cases,  however,  e.g.  ill- 
drained  wounds,  and  abscesses,  stagnant  urine,  etc.,  there  is  in  the 
body  an  ample  supply  of  dead  material  in  which  non-pathogenic 
organisms  thrive  and  produce  their  toxines,  which,  being  absorbed, 
give  rise  to  pathological  phenomena. 

Some  organisms  {e.g.  B.  anthracis)  require  free  oxygen,  others 
are  killed  by  it,  or  at  least  sustain  an  arrest  of  development ;  the 
former  are.  called  aerobic,  the  latter  anaerobic,  and  either  may  be 
obligate  or  facultative. 

All  organisms  require  water,  carbon,  hydrogen,  nitrogen,  oxygen, 
and  salts,  especially  potassium  and  phosphates.  Unlike  plants, 
they  cannot  assimilate  carbon-dioxide,  since  they  do  not  contain 
chlorophyll.  The  necessary  food  elements  are  obtained  by  the 
splitting  up  of  fats,  albumens,  carbohydrates,  and  water. 

The  influence  of  temperature  is  very  marked,  30^-35°  C.  being 
that  most  suitable  for  growth.  The  limit  of  temperature  for  the 
growth  of  most  organisms  ranges  from  5"  to  50°  C ;  nearly  all 
die  at  boiling-point,  and  many  at  much  lower  temperatures.  All 
organisms  are  much  less  injuriously  affected  by  dry  than  by  moist 
heat. 

The  spores  are  far  more  resistant  to  the  effects  of  heat  and 
other  injurious  influences  than  are  the  mature  organisms,  a  fact  of 
extreme  importance  in  preventive  medicine. 

Conditions  unfavoupable  to  growth  and  development. — 
Temporary  withdrawal  or  diminution  in  the  supply  of  nutrient 
material,  or  unfavourable  conditions  as  regards  moisture,  tempera- 
ture, etc.,  necessarily  impair  the  vital  activity  of  micro-organisms, 
and,  if  of  sufficiently  long  duration,  prove  fatal.  Inimical  condi- 
tions do  not  necessarily  kill,  for  although  the  organisms  may  remain 
inactive  for  a  long  period  (the  spores  very  much  longer),  they  will 
again  grow  and  multiply  under  favouring  circumstances.  The 
influence  of  high  and  low  temperatures  has  already  been  mentioned. 


92  MANUAL  OF   SURGERY  chap. 

Desiccation  is  very  harmful ;  nothing  which  is  really  dry  can  putrefy. 
Some  organisms  withstand  desiccation  better  than  others,  and  the 
spores  of  all  are  very  resistant,  as  has  already  been  stated. 

Movement  of  the  medium  is  unfavourable  to  nearly  all  organ- 
isms, and  for  many  rest  is  essential.  Most  grow  better  in  an 
alkaline  or  neutral  medium.  Bright  sunlight  is  harmful,  but  prob- 
ably has  not  much  influence  provided  other  conditions  favour  the 
organism.  Certain  substances,  known  as  antiseptics  and  germicides, 
will  kill  micro-organisms  or  render  their  toxines  innocuous  (see 
chap.  i.  vol.  ii.).  Bacteria,  as  the  result  of  their  own  activity,  give 
rise,  ifiter  alia,  to  substances  hostile  to  themselves ;  such  sub- 
stances are  known  as  anti-toxines. 

In  common  with  other  forms  of  life,  bacteria  are  subject  to  the 
laws  of  struggle  for  existence  and  survival  of  the  fittest ;  if  any 
nutrient  medium  favourable  to  the  growth  of  several  kinds  of 
microbes  be  inoculated  with  them,  the  weakest  and  least  favoured 
will  perish  in  the  presence  of  the  stronger  and  more  fit.  Thus  a 
nutrient  fluid  containing  sugar,  into  which  numerous  organisms 
have  been  introduced,  will  undergo  lactic  acid  fermentation,  the 
B.  lactis  being  the  most  favoured;  if,  however,  .5  per  cent 
tartaric  acid  be  added,  torulse  gain  ascendency  and  excite  alcoholic 
fermentation. 

While  there  is  this  obvious  antagonism,  there  is  also  evidence 
to  show  that  certain  organisms  act  better  in  the  presence  of  others. 
Thus  ordinary  putrefactive  bacteria  give  rise  to  poisons  which  act 
deleteriously  on  the  cells,  and,  if  absorbed,  on  the  body  generally, 
hence  they  lessen  the  resisting  powers  and  pave  the  way,  so  to 
speak,  for  the  attacks  of  pathogenic  organisms.  Watson  Cheyne 
has  pointed  out  that  tubercular  joints  with  septic  sinuses  are  much 
more  often  complicated  by  general  tuberculosis  than  are  similar 
joints  without  septic  sinuses ;  and  it  is  further  known  that  staphylo- 
coccus pyogenes  aureus  and  albus  act  much  more  powerfully  when 
combined  (see  p.  40). 

Products  of  bacterial  action. — The  chemical  products  of 
bacterial  action  differ  in  different  organisms,  and  in  the  same  organ- 
ism under  varying  composition  of  the  nutrient  medium.  Some  of 
them  are  harmless,  and  therefore  of  no  clinical  importance ;  others 
are,  in  varying  degrees,  poisonous  {toxines) ;  while  a  third  group  are 
antidotal  and  protective  iatiti-toxines). 

As  yet  the  precise  nature  of  these  products  is  almost  unknown, 
although  unformed  ferments,  toxic  alkaloids,  and  albumoses  have 
been  isolated  in  many  instances.     It  would  appear  that  toxines 


VI  BACTERIA  93 

may  be  secreted  by  the  organism  itself,  or  may  arise  from  chemical 
changes  occurring  in  the  media  as  the  result  of  the  vital  activity  of 
the  organism.  Such  toxines  are  very  soluble  and,  being  absorbed 
into  the  blood,  produce  definite  chemical  effects,  sometimes  on  the 
body  as  a  whole,  at  others  showing  a  special  predilection  for  certain 
tissues  (f.^i^.  diphtheritic  paralysis,  in  which  the  diphtheritic  poison 
specially  affects  the  nerves).  In  some  cases  the  toxines  are  bound 
up  with  the  microbic  protoplasm  from  which  they  are  not  readily 
freed,  and  hence  such  organisms  possess  toxic  properties  even  when 
dead. 

Reproduction  by  fission  has  already  been  alluded  to  above  (p.  89). 

Some  bacilli  germinate  by  spores  as  well  as  by  fission.  When  a 
spore-bearing  microbe  has  attained 
its  full  development,  it  becomes 
granular,  and  a  series  of  highly 
refracting  bodies — the  spores — 
appear  in  its  interior,  where  they 
remain  until  freed  by  degenera- 
tive changes  which  lead  to  a 
splitting  up  and  disintegration  of 
the  parent  organism.  These 
spores  are  composed  of  proto- 
plasm and    an    investing    cellulose  Fig.  23.-Anthrax  bacilli  and  spores. 

sheath     of    considerable    density 

(whence  probably  their  great  powers  of  resistance  to  injurious 
agents) ;  they  develop  into  the  mature  organism,  and  the  process 
is  repeated  indefinitely. 

Mutability  of  species. — Some  pathologists  have  maintained 
that  all  micro-organisms  belong  to  one  species,  the  various  recog- 
nised forms  being  merely  stages  in  development.  This  opinion  is, 
however,  held  by  very  few,  and  is  opposed  to  the  weight  of  evidence. 
CHnically  we  never  see  anything  consistent  with  mutability  of  species ; 
on  the  contrary,  we  know^  that  certain  parasites  invariably  produce 
identical  pathological  phenomena,  no  matter  through  how  many 
generations  they  may  have  been  cultivated.  In  such  cultivations, 
moreover,  the  organisms  always  behave  in  the  same  way,  exhibiting 
the  same  affinities  and  dislikes. 

Cultivation  through  many  generations  has  never  shown  that  a 
micrococcus  can  become  a  bacillus  or  spirillum.  In  the  face  of 
these  important  negative  facts,  and  in  the  absence  of  any  sound 
confirmatory  observations,  we  may  safely  assume  that  unity  of 
species  is  highly  improbable. 


94  MANUAL  OF   SURGERY  chap. 

BACTERIA    IN    RELATION    TO    THE    LIVING    BODY 

Method  of  invasion. — Non-pathogenic  fungi,  being  incapable 
of  existing  in  living  tissues,  are  powerless  for  evil  and  soon  perish 
when  taken  into  the  body  by  means  of  food  or  air.  In  ill-drained 
abscesses  and  wounds  the  discharges  consist  of  dead  material,  and 
afford  fitting  pabulum  for  these  microbes  which  are  thus  enabled  to 
thrive  and  multiply ;  if  their  soluble  toxines  are  absorbed  by  the 
lymphatics,  general  septic  poisoning  is  produced  (Septic  Intoxica- 
tion). The  organisms  are  introduced  by  dirty  instruments,  sponges, 
fingers,  and  the  like. 

Pathogenic  fungi,  which  are  capable  of  living  in  the  fluids  and 
tissues  of  the  host,  may  be  similarly  introduced,  or  may  enter  by  the 
alimentary  or  respiratory  tracts,  especially  if  there  be  any  inflammation 
or  lesion  of  the  mucous  membranes.  Unhealthy  wounds  are  more 
suitable  for  bacterial  invasion  than  are  healthy  ones,  since  the 
vitality  and  natural  resistance  of  the  tissues  is  diminished.  Again, 
recent  wounds  are  more  liable  to  pathogenic  infection,  and  to  ab- 
sorption of  the  toxines  of  non-pathogenic  organisms  than  are  granu- 
lating wounds,  since  granulations  do  not  contain  lymphatics  (the 
paths  by  which  absorption  and  dissemination  occur),  and  thus  offer 
a  barrier — though  not  an  insuperable  one — to  infection. 

Mode  of  action  of  organisms. — Non-pathogenie  microbes 
act  by  means  of  the  toxic  properties  of  the  products  of  their  activity ; 
they  remain  strictly  localised  to  the  dead  matter  in  which  they  live, 
and  the  general  symptoms  are  directly  proportional  to  the  amount 
of  toxine  absorbed  (Septic  Intoxication). 

Pathog-enie  organisms,  on  the  other  hand,  spread  from  the  seat 
of  inoculation,  multiply  in  the  tissues  or  fluids,  and  induce  symptoms 
out  of  all  proportion  to  the  amount  of  the  original  dose. 

It  does  not,  however,  necessarily  follow  that  inoculation  is 
followed  by  infection,  since  the  dose  may  not  be  sufficiently  large, 
or  the  animal  may  prove  refractory  or  immune.  Some  pathogenic 
organisms  may  remain  strictly  localised  to  the  point  of  inoculation 
(B.  tetani  and  diphtherise) ;  some  spread  by  continuity  of  tissue 
only,  others  by  the  lymphatics  or  by  the  blood,  either  entering  the 
circulation  directly  through  the  vessels,  or  indirectly  through  the 
thoracic  duct.  Thus,  wound  diphtheria  is  a  purely  local  process 
showing  no  tendency  to  spread ;  hospital  and  spreading  traumatic 
gangrene  spread  by  continuity  of  tissue,  while  soft  chancre  and 
cellulitis  spread  by  the  lymphatics,  and  acute  septic  infection 
through  the  blood-stream. 


VI  BACTERIA  95 

Organisms  gradually  invading  the  body  by  local  infection  give 
rise  to  the  local  ififective  processes  and  cause  general  symptoms  by 
absorption  of  their  toxines  ;  those  spreading  by  the  blood-stream 
induce  general  i?ifecti7)e  processes^  and  the  organisms,  sometimes 
carried  to  distant  parts,  excite  inflammatory  changes  and  secondary 
centres,  each  of  which  is  a  focus  for  further  infection. 

The  effect  of  toxines  on  the  tissue  cells  is  to  lower  their  vitality 
and  lessen  their  powers  of  resistance,  so  laying  them  open  to 
attacks  from  without ;  thus  we  see  a  point  of  connection  between 
non-pathogenic  and  pathogenic  fungi,  the  toxines  of  the  former 
lessening  the  resistance  of  the  tissues,  and  thereby  producing  or 
increasing  a  predisposition  to  infective  processes.  In  many  diseases 
{e.g.  typhoid,  diphtheria,  tetanus)  the  gravity  of  the  symptoms  does 
not  depend  on  the  local  manifest  lesions,  but  upon  the  absorption 
of  toxines  or  toxine-forming  materials. 

Proneness  to  infection  —  predisposition  of  the  host. 
—  By  predisposition  we  mean  that  vulnerability  of  the  body 
or  tissues  which  makes  it  or  them  peculiarly  liable  to  become 
the  seat  of  infection  and  morbid  processes,  and  which,  more- 
over, influences  to  some  extent  the  course  and  severity  of  such 
disease. 

Animals  which  are  proof  against  infection  by  any  special 
organism  are  said  to  be  i??imu?te  to  it,  while  those  which  are  inocu- 
lated wdth  difficulty  are  spoken  of  as  refractory.  Although  we  know 
that  many  conditions  predispose  an  animal  to  disease,  or  render  it 
immune,  we  do  not  know  how  these  conditions  act.  Predisposition 
is  hereditary  or  acquired.  Hereditary  predisposition  may  be  accen- 
tuated by  any  condition  which  has  a  prejudicial  influence  on  the 
health,  and  may  be  increased  or  diminished  by  interbreeding. 
Again,  heredity  may  protect  a  whole  species,  or  only  certain 
individual  members.  Thus  we  know  that  the  tubercle  bacillus  is 
especially  fatal  to  guinea-pigs,  but  that  rats  are  refractory ;  house- 
mice  are  speedily  killed  by  a  septicaemic  virus  to  which  field-mice 
are  immune  ;  anthrax  easily  affects  mice  but  not  rats  ;  lastly,  syphilis 
is  probably  peculiar  to  man  (see  p.  169).  With  regard  to  individual 
susceptibility  it  is  a  matter  of  common  experience  that  during 
epidemics  some  persons  are  affected,  whilst  others,  equally  exposed 
to  infection,  and  apparently  not  more  robust,  escape.  It  is  well 
known  that  erysipelas  is  very  prone  to  repeatedly  attack  some 
persons  in  presence  of  the  most  trivial  wound. 

Age  is  a  potent  factor ;  thus  diphtheria,  scarlet  fever,  measles, 
and  acute  necrosis  especially  attack  the  young,  the  last  being  con- 


96  MAXUAL   OF   SURGERY  chap. 

fined  to  children ;  anthrax  kills  young  dogs  easily,  whilst  old  ones 
are  refractory. 

With  regard  to  acquired  predisposition,  many  factors  favour  the 
development  of  infective  processes.  Wounds  and  mechanical  injury 
predispose  in  two  ways — (i)  by  lowering  the  vitality  of  the  tissues,  and 
(2)  in  some  cases  where  extravasation  occurs  (e.g.  bruising),  organisms 
that  are  present  in  the  blood,  but  incapable  of  growing  in  it,  find 
their  way  into  the  damaged  tissues,  where  development  can  occur. 
The  seat  of  a  wound  (in  other  words,  the  point  of  inoculation)  may 
be  favourable  or  hostile  to  the  growth  and  spread  of  a  particular 
organism  ;  thus  the  bacillus  of  mahgnant  oedema  develops  only  in 
connective  tissue,  and  if  present  in  the  blood  is  incapable  of  doing 
harm. 

Diseases  of  the  pri}ncE  via;,  especially  of  the  kidneys,  chronic 
alcoholic  poisoning,  and  faulty  hygienic  surroundings  certainly  act 
as  strong  predisposing  factors.  Xo  doubt  in  all  these  cases  the 
retention  of  nitrogenous  waste  products  in  the  body,  by  affording 
ample  pabulum  for  the  organisms,  is  a  most  important  element  in 
predisposition.  If  the  kidneys,  skin,  etc.,  do  not  act  properly,  effete 
matters  are  not  excreted  in  sufficient  amount,  and  remain  stored 
in  the  body.  Diseases  of  the  heart  or  lungs,  bad  air,  and  over- 
crowding, limit  the  amount  of  oxygen  ;  oxidation  does  not  therefore 
take  place  to  the  full  extent,  and  nitrogenous  material  is  present  in 
excess.  Chronic  alcoholism,  by  diminishing  oxidation,  leads  to  a 
like  result. 

A  certain  dose  of  poison  is  necessary  before  any  effect  is  pro- 
duced, but  this  dose  varies  according  to  the  degree  of  predisposition 
or  immunity ;  the  greater  the  predisposition,  the  smaller  is  the  dose 
needful  for  inducing  disease. 

Micro-organisms  of  the  same  species  have  not  always  the  same 
degree  of  virulence ;  it  may  be  increased  or  attenuated,  either  by 
circumstances  naturally  occurring  or  artificially  induced ;  thus,  cow- 
pox  is  in  all  probability  only  an  attenuated  form  of  smallpox. 
Attenuation  of  a  virus  naturally  diminishes  its  power  for  evil,  and  a 
larger  dose  is  necessary  to  produce  results. 

Immunity. — An  animal  is  said  to  be  immune  to  an  infectious 
disease  when  inoculation  fails  to  produce  it. 

Immunity,  like  predisposition,  is  natural  or  acquired  by  inherit- 
ance and  natural  selection  among  those  subjected  to  the  influence 
of  any  given  pathogenic  organism,  the  fittest  and  least  susceptible 
surviving  and  transmitting  their  powers  of  resistance  to  their 
offspring.     Yet  this  does  not  explain  in  the  least  what  the  nature  of 


VI  BACTERIA  97 

the  physiological  difference  in  the  cells  or  fluids  of  susceptible  and 
immune  animals  may  be ;  neither  are  the  changes  understood  by 
which  such  cells  or  fluids  in  susceptible  animals  become  immune 
after  being  once  attacked.  One  attack  of  a  general  infective  disease 
(e.g.  smallpox)  confers  immunity,  though  probably  only  for  a  certain 
length  of  time ;  such  immunity  is  not,  in  the  majority  of  cases, 
acquired  by  attacks  of  the  local  infective  processes. 

Immunity  may  be  conferred  on  an  animal  artificially,  but  does 
not  endure  for  ever ;  thus,  in  vaccination,  immunity  to  smallpox 
only  extends  over  a  limited  number  of  years  unless  the  operation 
be  repeated.  Such  artificial  immunity  may  be  produced  by  inocu- 
lation with  the  attenuated  virus,  or  with  small  doses  of  its  toxines  ; 
the  latter  method  has  this  great  advantage  over  the  former,  that  as 
no  living  organisms  are  introduced,  there  can  be  no  increase  of  the 
poison  in  the  body. 

The  products  of  the  virus,  used  in  small  doses,  probably  pre- 
pare the  cells  to  tolerate  larger  ones,  just  as  we  see  toleration 
established  in  opium  and  arsenic  eaters ;  or  it  may  be  that  the 
virus  so  alters  the  chemical  composition  of  the  media  that  the 
organisms  no  longer  find  the  pabulum  suitable  to  their  require- 
ments. 

The  blood  serum  of  an  animal  rendered  immune  artificially^  if 
injected  into  a  susceptible  animal,  renders  it  immune ;  or,  if  it  be 
already  attacked  by  the  disease,  serves  to  check  its  course  and 
severity,  and  to  bring  about  recovery.  This  fact  is  made  use  of  in 
the  anti-toxine  treatment  of  diphtheria  and  other  conditions.  What 
the  substance  or  substances  are  upon  which  this  protective  property 
of  the  serum  depends  we  do  not  know  ;  they  are  provisionally  called 
anti-toxines  or  defensive  proteids.  It  must  not  be  forgotten  that 
the  blood  serum  of  a  healthy  animal  possesses  germicidal  properties, 
but  blood  serum  as  such  is  not  present  in  the  living  body.  It  has 
not  been  shown  that  the  blood  serum  of  an  animal  naturally  immune 
to  any  disease  confers  immunity  on  susceptible  animals. 

It  is  highly  probable  that  the  method  of  production  of  immunity 
is  not  always  the  same,  and  one  would  naturally  expect  that,  as  the 
methods  of  invasion  and  growth  of  different  organisms  vary,  so 
would  also  the  means  of  protection. 

At  the  present  time  there  are  two  leading  views  as  to  the  nature 
of  immunity ;  some  hold  that  the  changes  are  vital  (phagocytosis), 
others  that  they  are  cherliical. 

Phagocytosis. — Metchnikoff  and  his  followers  mamtain  that 
certain  of  the  leucocytes  and  the  endothelial  cells  of  the  capillaries 

VOL.  I  H 


98 


MANUAL  OF   SURGERY 


CHAP. 


and  lymphatics  are  either  naturally,  or  may  be  artificially 
rendered  capable  of  destroying  poisonous  organisms,  and  thus 
protect  the  host  against  invasion.  In  susceptible  animals  these 
cells,  termed  phagocytes,  possess  this  power  in  a  limited  degree  or 
not  at  all.  The  theory  of  phagocytosis  suggests  that  on  the  intro- 
duction of  any  organism  or  noxious  matter  into  the  body,  a  war  for 
supremacy  is  waged  between  it  and  the  phagocytes,  the  result  to  the 
host  depending  on  the  issue  of  the  combat.  If  the  phagocytes  are 
very  active,  and  the  organisms  possess  only  slight  powers  of  resist- 
ance, the  latter  are  speedily  destroyed,  and  their  characteristic 
pathological   effects   are  not  produced — in   other  words,   the  host 


Fig.  24. — Anthrax  of  pigeon  (an  animal  only  slightly  susceptible  to  the  disease)  to  show  the  stages 
of  destruction  of  h^cilli  bj*  phagocytes.  i,  macrophage  from  exudation  from  the  eye  of 
refractor%'  bird  :  2,  macrophage  from  muscle  of  region  of  inoculation  of  bird  that  succumbed  ; 
3,  4.  5,  microphages  from  the  eye  twenty -seven  hours  after  inoculation;  a,  a,  unaltered 
bacilli ;  ^1,  h^,  i^,  bacilli  becoming  more  and  more  degenerated  and  indistinct ;  c,  c.  debris  of 
bacillL     (Allbutt's  Sj'sfe?>i  0/ Medic i7U,  after  Metchnikoff.) 

proves  immune  :  if  the  disproportion  in  strength  of  the  combatants 
is  not  so  marked,  the  disease  is  contracted  in  a  mild  or  severe 
form  ;  lastly,  if  the  organisms  are  much  stronger  than  the  phagocytes, 
they  invade  the  host  and  bring  about  a  fatal  result. 

Phagocytic  cells  are  chiefly  derived  from  the  leucocytes,  of  which 
the  blood  contains  four  forms  : — 

(i)  Lymphocytes — cells  with  a  single  round  nucleus  and  a  little 
protoplasm. 

(2)  Mononuclear  leucocytes  or  macrophages,  similar  to  lympho- 

cytes, but  larger. 

(3)  Eosinophile    leucocytes,   with    a    large    lobed    nucleus    and 

granular    protoplasm.      They    are    formed    in    the   bone- 


VI    .  BACTERIA 


99 


marrow,  and  derive  their  name  from  the  fact  that  they 
stain  only  with  acid  aniHne  dyes,  such  as  eosin. 

(4)  Polynuclear  leucocytes  or  microphages.  The  nucleus  is 
lobed  or  multiple. 

Of  these  cells,  the  macrophages  and  microphages  alone  act  as 
phagocytes. 

Vascular  and  lymphatic  endothelial  cells  are  capable  of  acting 
as  "  fixed  "  phagocytes,  but  are  also  sometimes  found  free  in  the 
vessels.  Phagocytes  are  sensitive  cells,  and  are  attracted  or  repelled 
by  certain  substances  or  organisms ;  attraction  is  spoken  of  as  posi- 
tive, repulsion  as  negative  chemiotaxis,  and  indifference  on  the  part 
of  the  leucocyte  is  called  neutral  chemiotaxis.  The  chemiotactic 
state  of  the  cells  as  regards  any  organism  is  a  matter  of  great 
moment ;  positive  chemiotaxis  determines  a  migration  of  leucocytes 
to  the  damaged  or  invaded  spot,  where  they  then  endeavour  to 
ingest  and  destroy  the  invaders ;  negative  chemiotaxis,  by  repelling 
the  leucocytes,  enables  the  organisms  to  invade  the  body. 

In  support  of  the  theory  of  phagocytosis,  the  following  observa- 
tions are  of  miportance.  It  is  well  known  that  amcebae  ingest  and 
live  upon  bacteria  and  low  forms  of  fungi.  In  higher  organisms, 
with  differentiation  of  structure,  the  same  process  occurs ;  thus,  in 
sponges,  the  mesoderm  cells  act  as  phagocytes ;  and  Woodhead  has 
noticed  that  in  the  growing  cod's  ova  all  the  cells  take  up  the  yolk 
masses  in  the  early  stages,  but  that  as  development  proceeds  this 
function  is  confined  to  the  mesoderm  cells  alone.  Phagocytosis 
also  plays  an  important  part  in  the  evolution  of  certain  larvae ;  thus 
the  tadpole's  tail  is  removed  by  phagocytic  action.  We  know, 
moreover,  that  catgut  ligatures  and  effete  material  are  removed  by 
leucocytes ;  yet  in  these  cases  it  must  be  obsers-ed  that  the  ingesta 
are  not  living,  and  have  no  powers  of  resistance  other  than  their 
physical  properties  give  them. 

When  anthrax  bacilli  are  injected  into  the  blood-stream  of  a 
frog,  they  are  ingested  and  destroyed  by  the  leucocytes,  and 
Metchnikoff  has  shown  that  when  daphnia  (water-flea)  is  attacked 
by  monospera,  the  leucocytes  show  marked  activity  {positive 
chemiotaxis\  crowding  round  and  destroying  the  parasite  ;  but  if 
daphnia  is  invaded  by  another  parasite  (saprolegnia),  the  leucocytes 
are  peculiarly  impassive  {negative  cke?niotaxis\  the  parasite  thus 
gains  ground  and  kills  the  host.  In  fatal  cases  of  erysipelas  in 
man,  the  organisms  are  not  taken  up  by  the  leucocytes,  but  in  more 
favourable  cases  they  are,  very  few  being  then  found  in  the  tissues. 
Animals  immune  to  any  organism  will,  if  the  spleen  be  previously 


loo  MANUAL  OF  SURGERY  chap. 

removed,  rapidly  succumb  to  inoculation  ;  this  fact  certainly  tends 
to  support  the  theory,  since  the  spleen  is  the  factory  for  leucocytes, 
but  unfortunately  its  value  is  discounted  by  our  ignorance  of  the 
functions  of  the  organ. 

While  the  fact  of  phagocytosis  is  acknowledged  by  all,  the  part 
claimed  for  it  in  the  protection  of  the  host  is  disputed.  Metchni- 
kofifs  opponents  do  not  deny  that  the  phagocytes  assemble  round 
the  areas  of  bacterial  invasion  ;  yet  they  contend  that  this  is  not  for 
purposes  of  aggression,  but  merely  because  they  find  in  the  dead 
and  dying  tissues  and  organisms  a  pabulum  suitable  to  their  needs ; 
and  that  when  living  organisms  are  met  with  in  the  cells,  they  are 
the  aggressors,  and  are  actually  killing  the  leucocytes.  Doubtless 
many  of  the  leucocytes  do  perish  in  the  struggle  for  supremacy.  It 
must  be  remembered  that  many  organisms  are  non-motile,  and  in 
the  case  of  these,  at  least,  it  is  impossible  that  they  could  have 
penetrated  the  leucocytes ;  they  must  therefore  have  been  taken  up 
by  them. 

The  chemical  or  humoralist  theory  asserts  that  organisms  are 
killed,  not  by  cells,  but  by  the  fluids  of  the  blood.  It  has  already 
been  stated  that  the  serum  of  animals  rendered  artificially  immune 
confers,  when  injected,  immunity  on  susceptible  animals.  Blood 
serum  may,  it  is  stated,  exert  a  protective  influence  in  two  ways — 
(i)  by  a  definite  bactericidal  action  on  the  organisms  themselves, 
and  (2)  by  antagonising  the  toxines  of  bacterial  action,  and  render- 
ing them  harmless.      The  two  processes  may  be  combined. 

The  defensive  action  of  serum  is  said  to  be  due  to  the  presence 
of  nuclein,  derived  by  the  disintegration  of  leucocytes  (phagocytes). 
This,  if  true,  is  in  part  at  least  an  acknowledgment  that  leucocytes 
have  themselves  the  power  of  killing  organisms,  since  it  is  only 
reasonable  to  suppose  that  if  leucocytes  contain  a  substance  possess- 
ing germicidal  properties,  they  can  themselves  be  germicidal.  The 
only  alternative  to  this  proposition  lies  in  supposing  that,  as  in  the 
case  of  the  fibrin-ferment,  the  toxic  properties  of  nuclein  are  only 
developed  when  it  is  freed  from  the  cells  and  mixed  with  the  fluid 
parts  of  the  blood.  Against  this,  Woodhead  has  shown  that 
animals  in  which  the  leucocytes  have  been  extensively  destroyed 
by  quinine,  are  more  susceptible  to  anthrax  than  they  were  before, 
an  observation  materially  strengthening  the  phagocytic  view.  To 
test  the  bactericidal  action  of  the  fluids  of  the  blood,  Schultze 
introduced  into  the  veins  and  lymph  sacs  of  animals  and  frogs  small 
boxes  made  of  rose-pith,  and  filled  with  the  spores  of  pathogenic 
organisms.     The  filtering  action  of  the  pith  kept  out  the  leucocytes, 


VI  BACTERIA  loi 

but  allowed  fluids  to  pass  into  the  boxes.  Schultze  found  that  so 
far  from  being  killed,  the  spores  developed  and  multiplied. 

Future  experiments  will  no  doubt  throw  more  light  on  this 
question  of  immunity,  and  it  seems  likely  that  the  two  theories  may 
be  harmonised.  Some  authorities  have  endeavoured  to  reconcile  the 
two  views.  They  point  out  that  the  fluids  of  the  body  must  be 
regarded  as  the  expression  of  the  vitality  of  the  cells,  that  any 
properties  these  fluids  possess  are  due  to  the  activity  of  the  cells, 
and  that  any  cell  capable  of  conferring  anti-toxic  properties  on  a 
fluid  must  surely  itself  be  anti-toxic. 

It  is  possible  that  the  organisms  themselves  are  destroyed  by 
the  phagocytes,  while  their  toxines  are  neutralised  and  rendered 
harmless  by  the  fluids,  the  anti-toxic  properties  of  which  may  be 
increased  by — or  may  even  depend  upon — the  breaking  down  of 
those  phagocytes  which  perish  in  the  combat.^ 

1  For  further  information,  see  The  Comparative  Pathology  of  Inflammation,  by 
Metchnikoff. 


CHAPTER    VII 

Surgical  Septic  and  Infective  Diseases 

Definition  and  classification. — The  word  septic  is  often  used 
as  a  generic  term  applied  to  diseases,  the  symptoms  of  which  are 
chiefly  dependent  upon  the  action  of  poisons  due  to  the  presence  of 
micro-organisms.  This  generic  use  of  the  word  too  frequently  gives 
rise  to  confusion,  especially  in  the  mind  of  those  who  are  com- 
mencing the  study  of  surgery,  and  it  should  be  used  in  a  very  much 
more  restricted  or  qualified  sense. 

Septicaemia  and  pyaemia  are  terms  similarly  employed  in  a  very 
loose  way  ;  although  sanctioned  by  long  usage  it  would  be  much 
better  if  the  former  at  least  were  abandoned,  including  as  it  does 
pathological  processes  of  very  different  aspect,  though  at  the  same 
time  they  have  this  in  common — they  are  all  due  to  poisoning.  It 
is  proposed  here  to  adopt  that  nomenclature  and  classification 
which  appears  to  be  the  best  and  the  most  likely  to  convey  exact 
ideas  as  to  the  nature  of  the  diseases  to  be  considered  in  this  and 
succeeding  chapters. 

Simple  septic  diseases  are  those  which  are  due  to  the  absorption 
of  poisons  generated  by  ordinary  putrefactive  decomposition.  The 
organisms  producing  these  poisons  are  non-pathogenic,  and  hence 
are  incapable  of  living  in  the  body  unless  there  is  some  dead 
material,  e.g.  pus,  blood-clot,  or  urine  present  which  serves  as  a 
suitable  pabulum.  The  clinical  symptoms  induced  are  directly 
proportional  to  the  dose  of  poison  absorbed.  The  conditions  be- 
longing to  this  group  are — 

(i)  Acute  septic  intoxication. 

(2)  Chronic  septic  intoxication  or  hectic. 

(3)  The  constitutional  effects  of  poisoning  bydecomposing  articles 

of  dietary,  or  in  some  cases  {e.g.  fish-poisoning)  by  fre^h  food. 


CHAP.  VII 


SEPTIC   INFECTIVE   DISEASES 


103 


Infective  diseases  are  dependent  on  the  absorption  of 
poisons  produced  by  pathogenic  organisms  which  are  capable  of 
multiplying  in  the  living  body  quite  irrespective  of  the  presence 
of  dead  material,  and  hence  of  inducing  symptoms  out  of  all  pro- 
portion to  the  amount  of  the  original  dose.  These  diseases  may 
be  local  or  general ;  but  it  must  be  understood  that  many  which 
are  here  classed  as  local  may  terminate  fatally  by  general  infection. 
Such  a  termination  may  be  due  to  mixed  infection,  or  may  depend 
upon  the  fact  that  organisms  usually  remaining  local,  may  under 
favourable  conditions  be  absorbed  into  the  blood  and  cause  general 
infection. 

A.  Local  infective  diseases  are  excited  by  microbes  which  spread 
locally  only  and  not  by  means  of  the  blood-stream,  although  .their 
toxines  can  be  and  are  absorbed  and  give  rise  to  constitutional 
symptoms. 

The  following  diseases  fall  under  this  category : — 
(i)  Boil,  carbuncle,  and  facial  carbuncle. 

(2)  Malignant  pustule  (external  anthrax).^ 

(3)  Cancrum  oris,  noma  vulvae. 

(4)  Hospital  gangrene. 

(5)  Sloughing  phagedaena. 

(6)  Wound-diphtheria. 

(7)  Cutaneous  erysipelas.^ 

(8)  Cellulo-cutaneous  erysipelas. 

(9)  Celluhtis. 

(10)  Emphysematous  gangrene. 

(11)  Rabies.^ 

(12)  Tetanus. 

(13)  Actinomycosis. 

(14)  Madura  foot. 

(15)  Tubercle.^ 

(16)  Gonorrhcea.^ 

(17)  Chancroid. 

B.  General  infective  diseases  are  those  due  to  the  presence  of 
pathogenic   organisms  which   gain   entry   into    the    blood  current, 

1  Malignant  pustule,  tubercle,  and  gonorrhcea  may  become  general  diseases. 
The  first  is  really  the  effect  produced  by  the  local  inoculation  of  anthrax,  but  early 
and  radical  treatment  may  prevent  general  infection  by  the  blood-stream.  Gonorrhoea 
is  essentially  a  local  process,  but  in  some  cases  of  gonorrhoeal  rheumatism  the 
gonococcus  has  been  found  in  the  synovial  effusion. 

^  Opinions  are  di\ided  as  to  whether  erysipelas  should  be  regarded  as  a  local  or 
general  infective  process  (see  p.  123). 

^  As  the  organism  of  rabies  has  not  yet  been  discovered,  the  disease  is  pro- 
visionally placed  here. 


I04  MANUAL  OF  SURGERY  chap. 

either  directly  through  the  veins  or  indirectly  through  the  lymph 
channels,  and  thus  produce  multiple  foci  of  disease. 
The  diseases  included  under  this  heading  are — 
(i)  Septic  infection. 

(2)  Septic  infection  with  secondary  centres  of  suppuration. 

(3)  Glanders. 

(4)  Syphilis. 

The  relation  between  septic  and  infective  processes. — 
The  occurrence  of  mixed  infection  has  been  already  alluded  to  at 
p.  95.  There  is  no  necessary  connection  between  a  septic  and  an 
infective  process,  but  in  practice  we  find  that  when  a  wound  is  the 
seat  of  an  infective  process,  putrefactive  decomposition  and  simple 
septic  absorption  are  also  present.  It  must  be  borne  in  mind  that 
this  does  not  necessarily  imply  the  association  of  different  forms  of 
organisms,  because  many  pathogenic  microbes  are  also  facultative 
saprophytes,  being  capable  of  causing  an  infective  and  a  simple 
septic  process. 

It  is  of  paramount  importance  in  preventive  treatment  to 
thoroughly  appreciate  the  fact  that  a  septic  condition  of  a  wound 
is  the  most  favourable  for  the  development  of  an  infective  organism. 
Putrefactive  decomposition  of  discharges  predisposes  to  infection  in 
two  ways : — 

(i)  By  lowering  the  resisting  powers  of  the  tissues  by  the  local 
and  general  effects  of  the  poisons  absorbed. 

(2)  By  setting  up  inflammation  and  consequently  providing  dis- 
charge which  serves  as  an  excellent  medium  for  the  de- 
velopment of  pathogenic  organisms,  many  of  which  are,  as 
already  stated,  facultative  saprophytes. 

If  infection  is  the  primary  process,  the  inflammation  at  the  seat 
of  inoculation  is  accompanied  by  copious  exudation,  and  thus  dead 
material  is  provided  which  serves  as  a  suitable  culture  medium  for 
any  saprophytic  organisms  which  may  be  present.  Doubtless  in  all 
the  infective  processes  the  general  disturbance  is  partly  due  to  the 
toxic  effects  of  the  poisons  formed  in  the  process,  and  partly  to 
ordinary  septic  intoxication,  and  hence  it  is  easy  to  see  why  the 
symptoms  may  show  improvement  when  the  wound  is  thoroughly 
drained  and  cleaned  so  that  putrefaction  is  prevented  or  the 
absorption  of  its  products  hindered. 

Causes  favouring  the  development  of  septic  and  in- 
fective processes. — The  mere  presence  of  organisms  is  not  in 
itself  sufficient  to  excite  the  pathological  changes  consequent  on  their 
action ;  there  must  be  certain  favouring  conditions  of  their  environr 


VII  SIMPLE  SEPTIC   DISEASES  105 

ment.  This  subject  has  already  been  discussed  at  p.  90,  and  here 
it  will  only  be  necessary  to  briefly  review  the  factors  which  are  of 
the  greatest  practical  importance  to  surgeons.  It  must  be  remem- 
bered that  these  predisposing  conditions  do  not  always  bear  the 
came  relative  proportion  in  etiology,  for  we  know  that  organisms 
are  sometimes  more  virulent  than  at  others,  and  that  certain 
persons,  animals,  or  tissues  are  naturally  predisposed,  refractory,  or 
immune  to  their  influence,  see  p.  95. 

The  predisposing  cause,  par  excellence^  is  faulty  hygiene, 
especially  overcrowding  of  surgical  patients.  Nothing  is  more 
certain  than  this ;  the  improvements  in  modern  sanitation  and  the 
introduction  of  antiseptics  have  virtually  abolished  many,  and 
rendered  comparatively  rare  nearly  all  of  the  surgical  infective 
diseases. 

A  wound,  although  it  may  be  of  minute  size,  is  always  present ; 
accidental  wounds  are  more  often  the  seats  of  these  processes  than 
are  surgical  ones,  since  the  latter  are  from  the  first  carefully  protected 
from  contamination. 

Punctured,  lacerated,  and  ill-drained  wounds  are  for  reasons 
already  given  (see  p.  94)  the  worst.  When  granulations  (which 
are  destitute  of  lymphatics)  have  sprung  up,  they  offer  a  barrier  to 
the  absorption  of  poisons  and  the  invasion  of  the  tissues  by  patho- 
genic fungi,  and  hence  recent  wounds  are  most  liable  to  infection. 

The  employment  of  antiseptics,  and  above  all,  the  complete 
cleansing  of  accidental  wounds,  is  an  essential  in  the  sanitation  of 
injuries,  especially  in  hospitals  and  crowded  cities.  Leaving  out 
of  the  question  individual  inherent  predisposition,  all  causes  {e.g. 
alcohol,  and  diseases  of  the  pri?nce  vice)  which  lower  the  general 
health  also  favour  the  occurrence  of  infective  processes,  the 
weakened  tissues  being  unable  to  cope  with  the  invading  organism. 

General  preventive  treatment. — A  knowledge  of  the  etiolo- 
gical factors  in  septic  and  infective  diseases  is  a  guide  to  the  general 
principles  of  preventive  treatment.  Free  drainage  of  wounds,  the 
strict  employment  of  antiseptics,  and  hygienic  surroundings  are 
essential.  Before  an  operation  is  performed  the  patient's  general 
health  should  be  brought  as  far  as  possible  up  to  a  normal 
standard. 

SIMPLE    SEPTIC    DISEASES 

The  organisms  capable  of  inducing  putrefaction  of  organic 
matter  are  known  as  saprophytes  or  carrion -fungi.      Those   most 


io6  MANUAL  OF  SURGERY  chap. 

usually  met  with  are  the  bacterium  lineola,  micrococcus  prodigiosus, 
bacillus  coli  communis,  bacillus  lactis  aerogenes,  and  proteus  vul- 
garis, but  many  pathogenic  fungi  are  facultative  saprophytes.  The 
products  of  decomposition  vary  with  the  organism  inducing  it,  with 
the  nature  of  the  decomposing  material,  and  with  the  conditions 
under  which  it  occurs.  Some  are  harmless,  others  poisonous,  the 
poisons  varying  in  their  virulence.  These  poisons  are  all  known  as 
ptomiaines  or  cadaveric  alkaloids. 

Sepsin,  cadaverine,  and  putrescine  are  common ;  muscarine, 
collodine,  parvoline,  and  others  are  found,  especially  in  de- 
composing fish.  Simple  septic  diseases  only  require  that  the 
poisonous  products  should  be  absorbed  into  the  system.  In 
recent  wounds  the  serum  and  blood-clot  are  dead  material,  ready 
to  putrefy  in  the  presence  of  the  ferment ;  pus,  urine,  and  other 
discharges  are  similarly  capable  of  putrefaction. 

But  even  should  putrefaction  occur,  it  is  by  no  means  certain 
that  absorption  of  the  ptomaines  will  follow.  If,  as  in  the  case  of 
an  open  or  well-drained  wound,  the  putrefying  discharges  find  easy 
exit,  absorption  is  not  likely  to  occur ;  but  if  there  is  any  tension, 
the  lymphatics  and  capillaries  readily  take  up  the  ptomaines.  In 
the  case  of  granulating  wounds,  the  granulations,  being  devoid  of 
lymphatics,  offer  a  bar  to  absorption ;  but  even  in  these  it  may 
occur  if  tension  be  high,  the  poisons  then  percolating  through  the 
granulations  to  the  lymphatics  beyond. 

Not  only  may  absorption  take  place  through  wounded  surfaces, 
but  should  the  ptomaines  be  taken  with  the  food,  they  will  be 
absorbed  by  the  gastro-intestinal  mucous  membrane  (as  in  poison- 
ing by  sausages,  fish,  or  by  putrid  pus  from  the  lungs,  mouth,  etc.), 
and  produce  serious  or  even  fatal  consequences.  This  fact  is  of 
extreme  importance  from  a  medico-legal  point  of  view.^ 

Ptomaines  are  excreted  by  the  urine  and  faeces. 

ACUTE    SEPTIC    INTOXICATION ACUTE    SAPR/EMIA 

Symptoms. — The  symptoms  usually  make  their  appearance 
during  the  second  day  after  the  injury,  and  are  ushered  in  by  chills 
or  a  distinct  rigor,  with  a  rise  of  temperature  varying  from  ioi°- 
104°  F.,  which  remiains  continuous,  or  presents  slight  intermissions. 
Vomiting,  nausea,  anorexia,  thirst,  and  constipation  are  usually 
present,  but  in  severe  cases  there  is  profuse  watery  diarrhcea  with 

^  For  a  full  account  of  septic  absorption  through  the  alimentary  tract,  the  reader 
is  referred  to  works  on  medicine. 


VII  ACUTE  SEPTIC   INTOXICATION  107 

perhaps  bloody  mucus.  The  tongue  is  furred,  the  breath  foul,  the 
skin  hot  and  dry,  the  urine  scanty,  rich  in  lithates,  and  sometimes 
albuminous.  The  pulse  is  rapid  and  perhaps  irregular,  and  head- 
ache is  usually  severe. 

If  the  dose  has  been  large,  collapse  and  nervous  prostration  are 
prominent  features;  the  tongue  becomes  dry  and  covered  with  sordes, 
and  there  is  diarrhcea  and  profuse  sweating.  The  headache  passes 
off  as  delirium  comes  on,  and  this  deepens  to  coma  before  death. 

The  amount  of  the  dose  and  the  rapidity  of  its  absorption 
cause  much  variety  in  the  effects  and  symptoms.  The  onset  may 
be  tumultuous  and  death  rapidly  ensue,  but  such  cases  are  hardly 
ever  seen  in  surgical  practice ;  they  may,  however,  occur  in  poison- 
ing by  putrid  food,  fish,  etc. 

In  other  cases  the  symptoms  are  but  little  marked,  and  come 
on  more  gradually,  so  that  with  prompt  treatment  the  patient  runs 
but  little  danger.      All  grades  of  severity  may  be  met  with. 

Diagnosis. — The  diagnosis  from  septic  infection  is  at  first 
impossible  ;  it  must  be  made  on  the  course  which  the  case  runs 
and  the  effects  produced  by  the  removal  of  all  putrid  matter. 
From  simple  aseptic  traumatic  fever,  sapraemia  may  be  distinguished 
by  the  greater  severity  and  more  lasting  nature  of  its  symptoms,  and 
by  evidences  of  decomposition  which  are  wanting  in  the  former 
state  (see  chap.  ii.  vol.  ii.). 

Prognosis. — Until  it  is  clearly  ascertained  that  no  infective 
process  complicates  the  condition,  the  prognosis  should  be 
guarded.  Acute  sapraemia  in  surgical  practice  is  not  usually  a 
serious  affection,  provided  means  be  taken  to  prevent  any  further 
absorption.  The  symptoms  usually  disappear  in  from  two  to  seven 
diys.  Owing  to  extensive  destruction  of  the  red  blood  cells  the 
patient  is  rendered  more  or  less  anaemic. 

Post-mortem  appearances. — Decomposition  sets  in  rapidly 
and  the  abdomen  and  tissues  soon  become  distended  with  gases. 
There  is  marked  post-7nortem  staining  from  decomposition  of  the 
red  cells,  brought  about  by  the  action  of  the  poison. 

The  chief  noticeable  characters  about  the  viscera  are  acute 
congestion  with  cloudy  swelling,  and  occasionally  petechial 
haemorrhages  which  are  especially  noticeable  on  serous  membranes, 
the  secretion  from  which  is  slightly  increased.  The  spleen  is 
enlarged,  soft,  and  may  be  diffluent. 

Treatment  must  be  directed  (i)  to  the  prevention  of  further 
absorption;  (2)  to  combating  the  effects  of  the  poison  already  in 
the  system  ;  (3)  to  improving  the  patient's  health. 


io8  MANUAL  OF  SURGERY  chap. 

Further  absorption  is  prevented  by  thoroughly  cleansing  the 
wound,  by  rendering  it  aseptic,  and  by  providing  free  drainage, 
which  may  necessitate  its  enlargement  or  else  counter-openings. 
Any  inflammatory  state  of  the  wound  must  be  treated  by  such 
means  as  seem  suited  to  the  case,  and  which  have  already  been 
discussed  in  the  chapter  on  Inflammation. 

These  measures  alone  are  usually  followed  by  a  rapid  fall  of 
temperature  and  marked  general  improvement ;  should  this  not  be 
the  case,  the  prognosis  becomes  grave,  as  there  is  probably  some 
associated  infective  condition. 

So  far  we  do  not  possess  any  direct  antidote  to  the  cadaveric 
alkaloids.  They  are  excreted  with  the  urine  and  faeces,  and  therefore 
the  bowels  should  be  opened  and  kept  acting  regularly,  but  violent 
purging  must  be  avoided,  as  it  adds  to  the  prostration.  The  action 
of  the  skin  and  kidneys  must  be  promoted  by  diaphoretics,  diuretics, 
and  demulcent  drinks.  The  general  rules  of  treatment  in  fever 
cases  must  be  followed,  and  stimulants  given  in  quantities  regulated 
by  the  state  of  the  pulse  (see  p.  31). 

Sapraemia  leaves  the  patient  weakened  and  anaemic,  and  as 
soon  as  his  digestive  organs  permit  he  should  be  supplied  with  a 
generous  meat  diet.  Iron,  quinine,  and  the  mineral  acids  with 
small  doses  of  strychnia  are  the  best  tonics.  The  patient  should  be 
sent  to  the  country  as  soon  as  possible. 

CHRONIC    SEPTIC    INTOXICATION HECTIC 

If  repeated  small  doses  of  the  cadaveric  alkaloids  be  absorbed, 
the  patient  falls  into  a  condition  known  as  hectic  or  chronic  septic 
intoxication.  The  difference  between  this  condition  and  that  just 
described  may  be  familiarly  likened  to  that  between  a  man  who 
occasionally  and  one  who  habitually  takes  an  excess  of  alcohol. 
Hectic  is  especially  likely  to  occur  in  connection  with  chronic 
suppuration  of  bones  and  joints,  and  especially  large  spinal 
abscesses  and  pulmonary  cavities  which  have  become  putrid  and 
are  imperfectly  drained ;  it  cannot,  of  course,  occur  so  long  as 
the  abscess  remains  unopened,  as  until  then  the  saprophytes 
cannot  gain  an  entry. 

Symptoms. — Hectic  is  marked  by  general  decline  of  health, 
accompanied  by  a  nocturnal  rise  of  temperature  of  one  or  two 
degrees  with  morning  remissions.  Anaemia  from  destruction  of  the 
red  cells  by  the  ptomaines  is  very  marked ;  the  patient  becomes 
pale    and   waxy -looking,    and   muscular    weakness    is    pronounced. 


VII  LOCAL   INFECTIVE   DISEASES  109 

Contrasting  with  the  general  pallor  is  the  well-known  hectic  flush 
on  the  cheeks.  The  tongue  is  tremulous  (evidence  of  nervous 
weakness),  pale,  flabby,  and  teeth-indented.  The  appetite  is 
indifferent  and  capricious,  and  emaciation  keeps  pace  with  the 
decline  of  the  general  health  and  vigour.  As  the  case  progresses, 
diarrhoea  and  profuse  sweating  —  the  latter  occurring  in  the  early 
hours  of  the  morning — add  to  the  patient's  weakness.  The  urine  is 
scanty,  high-coloured,  and  rich  in  lithates.  The  pulse  is  frequent, 
and  the  heart  fails  in  proportion  to  the  general  weakness.  Delirium 
does  not  usually  occur. 

Prognosis. — Hectic  is  necessarily  fatal  unless  the  suppurative 
process  can  be  stopped  or  means  adopted  to  provide  free  drainage 
and  prevent  decomposition  and  absorption. 

Treatment  is  conducted  on  the  same  lines  as  in  acute 
saprasmia. 

If  the  suppurative  process  cannot  be  checked  by  less  radical 
means,  amputation  should  be  performed  when  the  disease  affects 
one  of  the  limbs. 

LOCAL    INFECTIVE    DISEASES 

The  virulence  of  the  organisms  inducing  these  processes  varies 
within  the  widest  limits  (compare  wound -diphtheria  and  hospital 
gangrene).  Some  of  them  remain  quite  localised  to  the  seat  of 
inoculation  {e.g.  B.  tetani,  B.  diphtherias) ;  others  spread  by  local 
invasion  only,  i.e.  by  direct  continuity  of  tissue ;  others  again,  e.g. 
cellulitis,  spread  by  continuity  of  tissue,  and  also  by  the  lymph 
paths,  as  evidenced  by  the  acute  lymphangitis  and  lymphadenitis 
they  occasion.  In  many  of  the  local  infective  processes  the  local 
results  are  of  small  importance,  the  danger  lying  in  the  absorption 
of  the  toxines  (as  in  tetanus) ;  while  in  others  the  local  state  may 
prove  of  a  very  serious  nature  (cellulitis,  diphtheria,  etc.) 

The  toxines  are  excreted  with  the  faeces  and  urine. 


FURUNCLE  OR  BOIL CARBUNCLE 

Boil  and  carbuncle  differ  in  the  intensity  and  extent  of  the 
destructive  process  rather  than  in  their  essential  nature  or  cause. 
Boils  often  appear  in  crops ;  carbuncle  is  single,  and  may  be  com- 
pared to  a  closely-set  group  of  boils.  A  boil  remains  localised,  but 
a  carbuncle  may  spread  widely  in  the  subcutaneous  tissue.  More- 
over, the  former  is  of  no  serious  importance,  while  the  latter  may  be 
attended  with  the  gravest  results. 


no  MANUAL   OF   SURGERY  chap. 

Causes. — Boils  chiefly  attack  young  patients,  whereas  carbuncle 
is  more  common  in  adults. 

General  debility,  diabetes,  bad  food,  with  an  excess  of  nitrogen- 
ous matter,  and  bad  hygienic  conditions,  are  favouring  causes. 
Friction  is  frequently  responsible  for  the  occurrence  of  a  boil  or 
carbuncle ;  both  are  common  about  the  neck,  especially  posteriorly, 
over  the  shoulders,  and  on  the  buttocks,  all  of  which  are  common 
seats  of  friction.  Pyogenic  organisms  are  met  with  in  both  condi- 
tions, the  staphylococcus  pyogenes  aureus  being  the  most  constant 
and  virulent  (see  p.  40). 

Morbid  anatomy. — The  organisms  gain  entrance  through  a 
hair-follicle  or  a  sebaceous  or  sweat-gland,  and  excite  acute  inflamma- 
tion of  the  true  skin,  which  extends  to  the  subcutaneous  connective 
tissue,  but  rarely  involves  the  deep  fascia.  The  inflammation  remains 
localised,  and  the  tension  of  the  exudate  leads  to  rapid  sloughing. 

In  the  case  of  a  boil  the  slough  is  surrounded  by  pus,  lying,  in 
fact,  in  the  middle  of  an  acute  abscess  which  bursts  by  one  central 
opening,  and,  after  separation  of  the  slough,  rapidly  heals. 

The  slough  formed  in  carbuncle  is  similar  to  that  of  a  boil ;  it 
is  ashen-gray  in  colour,  and  composed  of  dead  connective  tissue, 
infiltrated  with  leucocytes  and  coagulated  lymph  containing  micro- 
organisms. Numerous  small  pustules  form  on  the  surface,  and  pus 
escapes  through  several  openings  in  the  thin  and  undermined  skin. 
Many  of  these  coalesce  in  the  centre  by  destruction  of  the  inter- 
vening skin,  and  the  slough  is  exposed  at  the  bottom  of  a  ragged 
opening. 

On  separation  of  the  slough,  healing  usually  occurs  without 
trouble.  Infective  thrombosis,  followed  by  general  infection,  may 
result. 

Signs  and  symptoms. — The  signs  of  boil  are  too  well  known 
to  require  description.  A  carbuncle  is  usually  oval  or  circular  in 
shape,  and  may  attain  a  large  size  ;  it  is  raised  above  the  surrounding 
parts,  and  has  an  indurated,  usually  circumscribed  base.  The  surface 
of  the  skin  is  livid  and  congested,  and  soon  necroses. 

A  carbuncle  sometimes  shows  a  marked  tendency  to  spread, 
often  in  one  direction  only. 

The  pain  occasioned  by  boil  or  carbuncle  is  generally  severe, 
especially  in  naturally  tense  regions,  or  where  the  skin  is  tough,  e.j{. 
the  neck.  Constitutional  symptoms  are  not  usually  present  in  cases 
of  boils  ;  but  in  carbuncle  there  is  more  or  less  fever,  with  asthenic 
symptoms. 

Prognosis   of  carbuncle. — In  some  cases  the  disease  may 


VII  FURUNCLE  OR   BOIL— CARBUNCLE  iii 

prove  very  serious,  and  the  patient  dies  of  exhaustion  or  general 
blood-poisoning.  In  diabetics,  coma  may  supervene  and  prove  fatal. 
Evidence  of  phlebitis  is  a  grave  sign,  since  infective  emboli  may  be 
carried  to  different  parts,  and  set  up  secondary  areas  of  suppuration. 
Carbuncles  approaching  the  scalp  are  serious,  as  the  veins  of  the 
skull  may  be  affected. 

Renal  disease,  or  any  serious  constitutional  mischief,  naturally 
increases  the  gravity  of  the  case. 

Carbuncle  may  last  two  or  three  weeks,  or  as  many  months. 

Treatment  of  boiL — When  a  boil  is  threatened  it  may  fre- 
quently be  prevented  by  rem.oving  all  sources  of  irritation  and  protect- 
ing the  inflamed  part.  If  a  hair  is  present  in  the  centre,  it  should  be 
removed.  Moist  heat  in  the  form  of  fomentations,  or  bathing  with 
hot  water,  may  cut  short  the  process  and  prevent  suppuration,  or 
will  hasten  it  if  imminent.  Should  there  be  much  pain,  a  boil  may 
be  advantageously  incised ;  otherwise  it  may  be  left  to  burst,  and 
the  separation  of  the  slough  and  the  healing  process  be  hastened  by 
hot  boracic  fomentations.  Repeated  boils  usually  indicate  weak 
health,  which  must  be  treated  appropriately  to  the  conditions  causing 
it.  Sulphide  of  calcium  is  said,  perhaps  without  sufficient  reason, 
to  be  useful. 

Treatment  of  carbuncle. — Any  constitutional  disorder,  e.g. 
diabetes,  must  receive  its  proper  treatment.  Alcoholic  and  diffusible 
stimulants,  such  as  ammonia  and  ether,  with  quinine  and  bark,  are 
required  in  view  of  the  asthenic  state  of  the  patient.  Opium,  in 
gradually  increasing  doses,  is  a  most  valuable  remedy,  especially  in 
diabetes ;  but  it  must  be  very  cautiously  given  in  cases  of  renal 
disease. 

The  action  of  the  bowels  and  kidneys  must  be  promoted.  The 
food  must  be  light  and  easily  digestible,  and  if  there  is  much  fever, 
slops  only  should  be  given ;  but  as  the  general  state  of  the  patient 
improves,  a  more  liberal  diet  may  be  allowed  with  advantage.  With 
regard  to  local  treatme?if,  opinion  still  differs  as  to  the  employment 
of  incisions  ;  they  are  undoubtedly  beneficial  if  tension  and  pain  are 
great.  The  incision  should  be  made  through  the  indurated  mass, 
haemorrhage  being  arrested  by  pressure.  Some  surgeons  recommend 
its  being  followed  by  removal  of  the  slough  with  the  sharp-spoon  ; 
but  this  is  rarely  advisable,  being  a  rather  more  severe  procedure 
than  the  patient's  condition  warrants.  The  injection  of  carbolic 
acid  into  the  sloughing  mass  has  met  with  some  success,  and  is 
worthy  of  trial,  especially  in  cases  where  more  active  treatment  is 
inadmissible  or  dangerous. 


112  .  MANUAL  OF  SURGERY  chap. 

x\ll  antiseptic  precautions  must  be  adopted,  and  hot  boracic 
fomentations  should  be  applied  until  granulation  is  established. 

FACIAL    CAREUN'CLE 

So-called  facial  carbuncle  is  considered  by  some  as  a  separate 
disease ;  but  it  is  probably  only  an  ordinary  carbuncle  running  a 
more  severe  and  fatal  course,  on  account  of  its  position  in  highly 
vascular  structures.  It  occurs  in  young  patients,  usually  between 
twenty  and  thirty  years  of  age.  Facial  carbuncle  is  usually  seen  on 
the  upper  lip.  It  begins  as  a  small  itching  pimple,  and  the  lip 
becomes  brawny,  livid,  and  painful.  The  swelling  is  not  circum- 
scribed, as  in  the  ordinary  form,  but  shows  a  remarkable  tendency 
to  spread  to  the  face  and  scalp,  or  downwards  towards  the  clavicle. 
Vesicles  form  over  the  brawny  swelling,  especially  on  its  mucous 
surface;  they  rapidly  become  purulent,  and  burst,  disclosing  the 
sloughy  tissue  bathed  in  pus.  Infective  phlebitis,  embolism,  and 
general  infection  are  very  common.  If  the  jugular  veins  are  involved, 
secondary  centres  may  form  in  the  lungs ;  or  if  the  facial  vein  in- 
flames, retrograde  phlebitis  may  give  rise  to  meningitis.  Chills,  or 
a  decided  rigor,  with  high  fever  and  marked  typhoid  symptoms,  are 
present  in  all  cases,  and  death  usually  results  from  exhaustion  or 
general  infection  in  four  or  five  days  or  less.  The  disease  must  be 
distinguished  from  malignant  pustule,  in  which  the  swelling  is  local- 
ised, is  covered  with  a  brown  dry  slough,  and  is  surrounded — not 
covered — by  a  ring  of  vesicles  (see  p.  n  4). 

Treatment. — As  for  carbuncle. 


MALIGNANT    PUSTULE LOCAL    OR    EXTERNAL    ANTHRAX 

Etiology. — Anthrax  may  occur  as  a  local  or  general  disease, 
the  latter  originating  by  inoculation  through  the  pulmonary  or 
intestinal  mucous  membrane,  or  following  the  local  affection  of  the 
skin. 

Malignant  pustule  is  dependent  upon  local  infection,  with  the 
bacillus  anthracis  at  the  seat  of  a  wound,  often  merely  an  insect  bite. 
It  may  probably  also  occur  through  the  sebaceous  or  sweat-glands, 
or  the  hair-follicles.  For  obvious  reasons,  it  is  most  usually  met 
with  on  exposed  parts — the  face,  hands,  and  forearms.  Anthrax 
is  common  in  all  herbivorous  animals,  especially  horned  cattle,  and 
in  this  country  inoculation  occurs  in  the  case  of  those  engaged 
in    the    preparation    of  hides  or  fleeces    imported  from  infected 


VII 


MALIGNANT   PUSTULE 


113 


districts.      Nearly  all   animals  can   be   inoculated,   but   many   are 
refractory. 

The    bacillus   a?ifhrads   is    a    non -motile,    rod -shaped,    aerobic 
organism,  with  cup-like  ends.      In 
the    living   body  it   multiplies   by 
fission    only,    but    externally    by 
spores  also.  n^^    *  ^^  V 

In    cultures    the    bacilli  grow   V       ^^      \         ^     ^ 
into  long  filaments,  and  form  in-      ^  w    ^      '^ 


>. 


Fig.  25. — ^Anthrax  bacilli  and  spores. 


terlacing   bundles,   but    this   does        ^  ~  ^    ^  %^     c^ 

not  occur  in  the  body. 

The  spores  are  extremely  re- 
sistant to  injurious  influences,  but 
may  be  killed  by  boiling. 

The  bacilli  spread  by  the  lym- 
phatics and  blood-stream,  and  are  found  in  great  numbers  in  the 
capillaries. 

The  toxines  are  an  albumose,  a  peptone,  and  an  alkaloidal  base. 
Leucin  and  tyrosin  are  also  found.  The  organism  can  be  attenuated 
by  repeated  inoculation  from  animal  to  animal,  and  a  protective 
serum  is  thus  obtained.  Protection  lasts,  however,  only  a  short 
time. 

Signs  and  symptoms. — After  inoculation  there  is  an  incu- 
bative stage  of  from  some 
hours  to  three  to  four 
days,  the  duration  de- 
pending on  the  dose  and 
virulence  of  the  organ- 
ism and  the  predisposi- 
tion or  otherwise  of  the 
host.  At  the  point  of 
inoculation  a  small  red 
pimple  forms,  accom- 
panied by  itching  and 
heat,  but  pain  is  absent 
throughout  the  disease. 
In  a  few  hours  the 
pimple  spreads  and  de- 
velops into  a  red,  indurated,  raised  carbuncular  patch,  surrounded 
for  some  distance  by  inflammatory  oedema  and  infiltration  of  the 
tissues,  which  may  be  shot  with  petechial  haemorrhages. 

Lymphangitis    and    lymphadenitis    are    excited,    the    former 

VOL.'-  *  1 


Fig.  26. — Malignant  pustule.  A,  central  slough;  B,  ring 
of  vesicles;  C,  area  of  induration  ;  D,  area  of  surround- 
ing congestion.     (Follin.) 


114  MANUAL  OF  SURGERY  chap. 

indicated  by  red  and  tender  lines  running  from  the  pustule 
towards  the  nearest  lymphatic  glands,  which  are  enlarged  and 
tender. 

Soon  after  the  appearance  of  the  pimple  a  small  vesicle  con- 
taining sanious  fluid  forms  on  it,  and  others  make  their  appearance 
in  the  centre  of  the  increasing  patch.  These  vesicles  may  rupture 
or  dry  up.  The  skin  beneath  is  at  first  a  purplish  colour,  but  soon 
dries,  and  turns  brown  or  black.  This  gangrenous  patch,  with  its 
adjacent  inflammatory  zone,  increases  in  area,  and  is  surrounded  by 
a  circle  of  vesicles  similar  to  those  which  form  over  the  sloughing 
skin  (Fig.  26,  p.  113).  The  slough  extends  to  the  connective 
tissue,  but  no  suppuration  occurs  until  it  begins  to  separate.  This 
absence  of  suppuration  is  very  characteristic,  affording  marked 
contrast  to  what  is  seen  in  carbuncle.  The  sloughy  tissues  are 
blood-stained,  as  extravasation  is  a  common  feature  of  the  lesion. 

The  inflammatory  reaction  round  the  pustule  is  much  more 
marked  in  a  few  hours  than  at  first,  and  serves  to  limit  the  process. 
Bacilli  are  found  in  the  contents  of  the  vesicles  and  in  the  superficial 
lymphatics,  but  not  in  the  blood  unless  general  infection  ensues ; 
nor  are  they  found  in  the  slough,  having  probably  been  killed  and 
disintegrated  so  as  to  become  indistinguishable. 

Constitutional  symptoms  may  be  entirely  absent,  and  the  patient, 
unmindful  of  the  local  condition,  continues  his  employment ;  more 
usually  there  is  some  rise  of  temperature  with  general  malaise.  If 
general  infection  ensues,  severe  symptoms  of  general  anthrax,  refer- 
able to  the  lungs  or  intestinal  tract,  make  their  appearance ;  marked 
dyspnoea,  vomiting,  bloody  diarrhoea,  and  cardiac  failure  being  the 
most  prominent.  For  a  full  account  of  general  anthrax  the  reader 
is  referred  to  a  work  on  Medicine. 

Diagnosis. — Malignant  pustule  must  be  distinguished  from 
carbuncle  and  facial  carbuncle.  The  chief  points  indicative  of 
malignant  pustule  are  the  patient's  exposure  to  infection  from  the 
nature  of  his  employment,  the  painless,  non-suppurative  course, 
the  presence  of  the  vesicles  in  the  centre  and  round  the  dry 
brown  slough,  and  the  mildness  of  the  general  symptoms.  The 
discovery  of  the  specific  micro  -  organism  in  the  discharge  by 
microscopic  examination,  or  by  inoculation  of  a  predisposed  animal 
is  conclusive  proof,  but  is  rarely  necessary. 

Prognosis. — The  prognosis  in  malignant  pustule  is  good,  pro- 
vided it  be  detected  early  before  signs  of  general  anthrax  are 
present  and  is  energetically  treated.  If  general  infection  has 
occurred,  the  patient's  chances  are  small. 


VII  CANCRUM   ORIS— NOMA  VULV^  115 

Spontaneous  cure  has  been  known,  but  must  by  no  means  be 
relied  on  to  the  exclusion  of  treatment. 

The  surrounding  inflammatory  oedema  is  on  account  of  its 
situation,  e.g.  the  neck,  sometimes  a  danger  by  its  possible  in- 
volvement of  specially  important  parts,  such  as  the  glottis. 

Treatment  must  be  energetic  and  early  adopted.  The  pustule 
must  be  completely  excised  and  the  wound  cauterised  either  with 
nitric  acid,  chloride  of  zinc  paste,  or  the  actual  cautery.  During 
excision  free  irrigation  with  i  :  2000  mercury  solution  is  advisable 
in  order  to  wash  away  the  blood  and  prevent  the  bacilli  gaining 
entrance  to  the  vessels,  as  general  infection  may  be  thereby  occa- 
sioned. The  veins  leading  from  the  part  may  be  compressed  with 
a  like  object,  but  no  compression  should  be  exercised  on  the  pustule 
itself;  the  wound  must  be  dressed  with  double  cyanide  gauze 
and  mercuric  cotton.  The  surrounding  cellulitis  will  usually  sub- 
side when  the  pustule  has  been  removed  ;  incisions  may  be  necessary 
for  threatened  suppuration,  which,  however,  is  rare. 

The  general  treatment  consists  in  the  use  of  stimulants,  quinine, 
and  good  diet,  as  in  the  infective  processes  generally. 

Ipecacuanha  has  been  shown  to  possess  germicidal  properties 
as  regards  the  B.  anthracis,  but  not  as  regards  the  spores.  This, 
however,  does  not  matter  from  a  clinical  point  of  view,  since  the 
latter  are  not  present  in  the  body.  The  powdered  drug  should  be 
given  in  five  or  ten  grain  doses  with  a  little  milk ;  the  dose  is  to  be 
repeated  every  six  hours. 


CANCRUM    ORIS NOMA    VULV^ 

Seat. — Cancrum  oris  or  noma  is  an  acute,  spreading,  gangrenous 
inflammation  met  with  in  young  children.  It  usually  occurs  in  the 
groove  between  the  lower  jaw  and  the  cheek,  and  may  originate  in 
ulceration  of  the  gums.  Occasionally  it  affects  the  mucous  surface 
of  the  vulva. 

Causes. — Noma  usually  attacks  cachectic  children  between  the 
ages  of  two  and  five  years.  The  poor  of  large  cities  are  specially 
liable  to  it.  The  subjects  of  noma  are  always  in  a  state  of  marked 
debility  either  from  starvation,  ill-feeding,  exposure,  or  faulty  hygienic 
surroundings,  or  from  a  recent  attack  of  one  of  the  acute  specifics, 
especially  measles  or  scarlet  fever. 

The  exciting  cause  is  the  presence  of  a  slender  bacillus  which 
is  found  in  the  sloughy  mass  and  in  the  margins  of  the  inflammatory 
area. 


ii6  MANX'AL   OF   SURGERY  chap. 

Signs  and  symptoms. — The  connective  tissue  beneath  the 
mucous  membrane  is  the  seat  of  copious  exudation  which  occasions 
much  sweUing.  The  cheek  is  swollen,  red,  hot,  and  brawny ;  the 
skin  is  stretched,  shiny,  and  smooth,  and  in  a  few  hours  the  most 
tense  portion  becomes  black  and  gangrenous,  and  perforation  of  the 
cheek  rapidly  follows. 

Movement  of  the  jaw  is  limited,  or  it  may  be  rigidly  closed  by 
the  swelling.  Salivation  is  profuse,  and  the  saliva,  mixed  with  dis- 
charge from  the  gangrenous  mass,  is  horribly  offensive.  If  the 
mouth  be  forced  open,  a  foul,  deep,  and  ragged  ulcer  covered  with 
a  dark  slough  is  seen  ;  the  jaw  may  be  denuded  and  the  loosened 
teeth  drop  out.  Pain  is  absent.  Venous  thrombosis  with  general 
infection  frequently  ensues,  or  the  fatal  termination  may  be  due  to 
septic  bronchitis  or  pneumonia.  The  constitutional  symptoms  are 
severe ;  there  is  high  fever  with  rapid  pulse  and  signs  of  failing 
heart.  In  a  few  hours  marked  typhoid  symptoms  make  their 
appearance,  the  child  becomes  apathetic  and  drowsy,  and  coma 
ushers  in  death,  which  usually  occurs  in  from  three  to  six  days. 
Very  few  cases  recover. 

Noma  of  the  vulva  runs  the  same  rapid  course  ;  it  usually  begins 
on  one  labium  and  extends  to  the  other  by  contact.  Death  occurs 
from  exhaustion  or  general  infection. 

Treatment  is  the  same  whether  the  disease  attacks  the  mouth 
or  vulva ;  to  be  effectual,  it  must  be  prompt  and  thorough. 

The  child  must  be  anaesthetised,  and  the  seat  of  the  disease  (as 
limited  by  the  induration)  must  be  thoroughly  cut  away  by  the 
knife,  scissors,  and  sharp-spoon  so  that  the  whole  area  of  infection 
is  removed.  As  soon  as  this  has  been  done  the  tissues  should  be 
thoroughly  cauterised  with  strong  nitric  acid  and  the  wound  packed 
with  gauze  saturated  with  iodoform  emulsion. 

The  mouth  should  be  irrigated  with  Condy's  fluid  or  chlorate 
of  potash  solution  (gr.  20  ad  gi)  every  hour.  If  the  disease  re- 
appears the  operation  must  be  repeated.  Nutritious  fluid  food  and 
stimulants,  with  the  internal  administration  of  chlorate  of  potash, 
are  the  general  measures  to  be  adopted. 

HOSPITAL    GANGRENE 

Hospital  gangrene,  regarded  by  many  as  identical  with  phage- 
daena,  is,  owing  to  improved  sanitation  and  antiseptics,  practically 
a  thing  of  the  past  in  civil  practice.  Formerly  it  was  one  of  the 
most  formidable  dangers  of  military  cam.paigns ;  in  the  Crimea  this 


VH  HOSPITAL  GANGRENE  117 

disease  proved  most  disastrous,  and  is  said  to  have  killed  more  men 
than  did  the  Russian  bullets.      In  modern  campaigns  it  is  very  rare. 

Hospital  gangrene  is  distinguishable  from  phagedaena  by  its 
greater  rapidity  of  spread,  its  more  highly  contagious  nature,  and 
its  higher  rate  of  mortality ;  phagedaena  is  not  so  virulently  con- 
tagious, and  occasionally  ceases  spontaneously  or  under  mild  treat- 
ment. No  doubt  all  grades  of  severity  are  met  with,  so  that  the 
two  diseases  merge  one  into  the  other. 

Causation. — Hospital  gangrene  is  associated  with  the  presence 
of  staphylococci  and  streptococci,  and  Koch  has,  by  inoculation  of 
mice  with  the  latter,  induced  a  gangrenous  affection  identical  in  its 
general  features  with  hospital  gangrene.  It  is  highly  contagious. 
Bad  hygienic  surroundings,  especially  the  overcrowding  of  surgical 
patients,  are  most  potent  predisposing  causes.  The  poison  may  be 
conveyed  to  the  patient  by  instruments,  sponges,  flies,  etc. 

Symptoms. — Hospital  gangrene  usually  attacks  recent  wounds. 
It  is  ushered  in  by  a  feeling  of  weight  and  severe  burning  pain  in 
the  part.  The  surface  of  the  wound  inflames,  and  is  covered  by  a 
thick,  pulpy,  loosely  adherent,  dirty  black  slough,  which  is  usually 
separated  from  the  inflamed  margin.  The  surrounding  tissues  are 
swollen,  livid,  oedematous,  and  inflamed,  and  speedily  die  by  ex- 
tension of  the  process.  The  edges  of  the  ulcer  are  steep,  everted, 
ragged,  and  often  undermined ;  when  cut  into,  the  infiltrated 
tissues  are  said  to  look  like  pork.  The  gangrene  spreads  super- 
ficially and  deeply,  gradually  destroying  muscles,  vessels,  etc.,  laying 
bare  bones  and  opening  joints.  The  vessels  usually  escape  so  long 
as  the  sloughs  are  adherent,  but  when  separation  begins,  profuse 
and  fatal  haemorrhage  may  occur.  The  discharge  from  the  gan- 
grenous area  is  horribly  foetid,  of  a  dark  colour,  and  often  bloody. 

In  less  formidable  cases  the  gangrene  does  not  extend  so 
deeply,  but  covers  a  larger  area ;  it  is  then  not  so  fatal. 

Restlessness,  sleeplessness,  general  asthenia,  and  ner\'Ous  pros- 
tration with  high  fever,  are  the  leading  constitutional  features. 
Typhoid  symptoms  soon  make  their  appearance ;  delirium  sets  in 
and  deepens  into  coma  as  the  end  approaches. 

Prognosis. — Nearly  all  cases  of  genuine  hospital  gangrene 
succumb.  It  is  stated  that  at  the  siege  of  Sevastopol  no  person 
who  was  attacked  by  hospital  gangrene  was  known  to  recover. 

If  the  process  be  temporarily  arrested,  a  relapse  may  occur  in  a 
few  days  and  carry  off"  the  patient. 

Treatment. — The  patient  and  those  nursing  him  must  be 
rigidly  isolated.     All  dressings  should  be  burnt  in  the  room,  and 


ii8  MANUAL   OF   SURGERY  chap. 

the  instruments  used  must  be  thoroughly  sterilised.  Free  stimula- 
tion and  large  doses  of  opium  and  quinine  must  be  prescribed. 
Locally,  the  most  drastic  measures  are  the  only  ones  of  any  avail. 
The  patient  must  be  anccsthetised  and  the  gangrenous  tissues 
freely  removed  by  the  sharp-spoon,  care  being  taken  that  no  large 
vessel  is  opened.  The  surface  must  then  be  rubbed  over  with  the 
actual  cauter}',  or  treated  with  pure  nitric  acid  or  chloride  of  zinc 
paste,  or  it  may  be  covered  with  Ricord's  paste  (sulphuric  acid  and 
willow  charcoal  in  equal  parts).  This  paste  dries  on  the  surface, 
and  in  from  twelve  to  thirty-six  hours  can  be  easily  removed,  leaving 
a  healthy  surface  beneath  :  it  must  be  reapplied  if  necessary.  If 
recovery  ensues,  the  wound  will  heal  by  granulation.  If  there  is  a 
relapse,  the  treatment  must  be  repeated. 

Amputation  may  be  required  in  case  of  relapse,  or  if  a  large 
vessel  gives  way  and  the  bleeding  cannot  be  controlled.  It  must, 
however,  be  remembered  that  amputation  is  a  very  serious  measure, 
and  that  the  patient  is  usually  in  too  feeble  a  condition  to  with- 
stand the  shock;  moreover,  the  gangrene  may  attack  the  stump. 
It  is  a  desperate  remedy,  but  under  the  circumstances  mentioned 
will  afford  the  patient  a  last  chance. 

SLOUGHING    PHAGED.^XA 

Sloughing  phaged^ena  closely  resembles,  if  it  is  not  identical 
with,  the  milder  cases  of  hospital  gangrene,  but  is  far  less  con- 
tagious. 

Causes. — In  the  main  the  causes  are  those  of  hospital  gangrene. 
Sloughing  phagedena  is  particularly  liable  to  occur  in  syphilitic  and 
soft  sores,  especially  if  they  are  concealed  under  a  tight  prepuce. 

Signs. — Assuming  the  disease  to  begin  in  a  venereal  sore. 
accompanied  by  phimosis,  so  that  cleanliness  cannot  be  properly 
secured,  there  will  be  considerable  inflammatory  swelling  with 
acute  pain.  The  prepuce  is  bulged  by  foul  discharge,  which  drips 
away  from  the  orifice ,  it  becomes  shiny,  tense,  and  of  a  livid  hue, 
and  a  small  black  area  marks  the  onset  of  gangrene.  The  pre- 
puce sloughs,  and  the  glans  penis  escapes  through  the  opening. 
Gangrenous  ulceration  rapidly  extends  in  superficial  area,  but  does 
not  usually  eat  deeply;  the  skin  of  the  penis,  scrotum,  perineum, 
groin,  and  abdomen  may  be  completely  destroyed.  In  the  case  of 
a  woman  recently  under  my  care  in  the  Westminster  Hospital,  a 
large  gangrenous  area  resulted,  involving  the  left  side  of  the  vulva, 
ischio -rectal   fossa,    perineum,    natcs,    thigh,    and  abdominal   wall 


VII  WOUND-DIPHTHERIA  119 

The  tissues  are  brawny  and  oedematous ;  the  surface  of  the  wound 
is  covered  by  a  dark  or  greenish  slough,  and  the  discharge  is 
horribly  offensive.  This  gangrenous  process  necessarily  masks  the 
original  venereal  sore. 

Very  often  there  are  practically  no  constitutional  symptoms 
beyond  a  slight  degree  of  fever ;  sometimes  they  are  similar  to 
those  of  hospital  gangrene. 

Prognosis. — The  rapidity  and  virulence  of  the  process  varies 
considerably ;  usually  it  spreads  rapidly,  at  other  times  more  slowly, 
and  may  even  be  spontaneously  arrested.  Recovery  is  the  rule, 
but  death  may  occur  from  exhaustion  or  septic  poisoning. 

Treatment. — The  general  treatment  consists  in  the  admini- 
stration of  opium  and  quinine,  with  stimulants  if  the  state  of  the 
patient  is  low.  Locally,  the  application  of  Ricord's  paste  is  most 
beneficial ;  the  sore  should  be  dried,  and  the  paste  freely  applied 
and  allowed  to  dry  on ;  it  may  be  reapplied  in  twenty-four  hours 
if  there  is  any  sign  of  a  continuance  of  the  disease.  The  prepuce, 
if  tight,  should  be  slit  up  to  expose  any  sore  beneath  it. 

In  milder  and  less  rapidly  spreading  .cases,  excellent  results 
follow  immersion  in  a  boracic  bath  at  a  temperature  of  about  100'' 
F.  The  patient  may  sit  in  this  for  seven  or  eight  hours ;  the 
sitting  should  be  repeated  after  an  interval  for  rest,  during  which 
the  parts  should  be  freely  dusted  with  iodoform  and  hot  fomenta- 
tions applied.  If  the  patient  can  stand  it,  the  sitting  may  be 
continuous.  The  baths  should  be  continued  until  all  sloughing 
ceases  and  the  sore  begins  to  heal. 

Should  phagedaena  occur  in  a  syphilitic  sore  mercury  will  be 
necessary,  but  if  the  patient  is  feeble  it  will  be  wiser  to  defer  its 
use  until  the  active  stage  of  the  sloughing  has  passed. 


WOUND -DIPHTHERIA 

Etiology. — Wound -diphtheria  is  probably  closely  allied  to 
sloughing  phagedcena,  but  has  much  less  destructive  tendencies, 
and  does  not  show  the  same  predilection  for  venereal  sores.  It 
usually  occurs  in  dirty  wounds  and  ulcers,  and  in  cachectic  patients, 
li\-ing  under  faulty  hygienic  surroundings.  Micrococci  are  present 
in  the  exudate. 

The  condition  sometimes  assumes  an  acute  form  very  like 
phagedena. 

Signs. — Lymph  is  effused  on  the  surface  of  the  wound,  and  the 
granulations  show  a  retrograde  tendency  and  may  be  the  seat  of 


I20  MANUAL  OF   SURGERY  chap. 

haemorrhage.  The  exudate  forms  a  tough,  grayish-white  membrane 
adherent  over  the  surface  of  the  wound,  the  edges  of  which  may  be 
slightly  swollen  and  inflamed ;  as  these  break  down,  the  ulcer 
increases  in  size.  The  process  is  generally  very  chronic  and  un- 
accompanied by  constitutional  symptoms,  but  should  it  assume  a 
phagedsenic  type,  the  local  condition  is  much  more  serious  and 
constitutional  symptoms  may  supervene.  The  contagiousness  of 
this  affection  is  slight. 

Treatment. — The  false  membrane  should  be  scraped  away,  the 
wound  sharp-spooned,  and  cauterised  with  chloride  of  zinc  paste  or 
nitric  acid.  The  general  health  must  be  improved  by  good  food. 
Quinine  and  opium  are  very  useful. 

Healing  is  usually  readily  induced  and  the  fear  of  recurrence 
under  antiseptic  treatment  practically,  ;///. 

SPREADING    TRAUMATIC,    OR    EMPHYSEMATOUS    GANGRENE 

Emphysematous  gangrene  is  a  local  infective  process  primarily 
attacking  the  subcutaneous  connective  tissue  and  causing  acute 
inflammation  and  death  of  the  affected  parts.  It  spreads  with 
great  rapidity,  subsequently  affects  the  muscles  and  deeper  struc- 
tures, and  usually  proves  fatal. 

Causes. — The  streptococcus  pyogenes  and  a  bacillus  closely 
allied  to,  if  not  identical  with  that   of  malignant  cedema,   are    the 

micro-organisms     exciting     this     disease. 

^  The  latter  organism  is  abundant  in   sur- 

•^/  -•  "*      p,/    face   soil    and   town  mud.       Chicken  are 

—  —  «o,  specially  susceptible  to  the  organism  which 

>^  >^  -^  -.    y       "^     is  often  found  in  the  earth  of  fowl-houses. 

" — *     /  It   develops    by  spores    outside,   but    not 

^  "^^^  inside  the  body. 

Fig.  27.  Emphysematous       gangrene       always 

Bacilli  of  malienant  cedema.  •  i.-  ".i  j 

*  occurs  m  connection  with  a  wound,  especi- 

ally in  drunkards,  or  in  cachectic  states  such  as  are  occasioned 
by  diabetes  or  renal  disease.  Contused  and  lacerated  wounds 
and  those  imphcating  joints  or  the  medullary  cavities  of  bones  are 
specially  liable  to  attack.  It  is  very  noticeable  that  wounds  which 
have  been  contaminated  with  the  mud  of  large  cities,  as  is  so  often 
the  case  in  compound  fracture,  are  highly  favourable  seats  of  this 
disease. 

Signs  and  symptoms. — Emphysematous  gangrene  attacks 
recent  wounds,  usually  making  its  appearance  about  the  second  or 


VII  EMPHYSEMATOUS  GANGRENE  121 

third  day.  Pain  and  heat  in  the  part,  with  some  constitutional 
disturbance,  lead  to  an  examination  of  the  wound,  which  will 
be  found  swollen,  inflamed,  and  discharging  a  brownish  foetid  fluid 
suggestive  of  pent-up  discharge.  The  swelling  rapidly  increases 
and  extends  up  the  limb,  especially  on  the  inner  side  where  the 
cellular  tissue  is  abundant  and  lax.  The  skin  is  of  a  livid  purple 
hue,  and  the  area  of  gangrene  is  marked  by  a  livid  blush.  The 
infiltrated  tissues  are  doughy  and  oedematous ;  they  crepitate  on 
pressure  from  the  presence  of  gases  evolved  as  the  result  of  decom- 
position, and  the  action  of  the  organisms  ;  hydrogen  and  carburetted 
hydrogen  are  the  most  important.  The  skin  is  studded  with 
blebs  which  contain  foetid,  discoloured  fluid,  and  the  cuticle  separates 
easily.  The  limit  of  the  superficial  blush  does  not  quite  correspond 
to  the  limit  of  the  disease,  as  the  connective  tissue  is  primarily  and 
the  skin  secondarily  affected — a  point  to  be  remembered  in  am- 
putating. 

The  gangrene  extends  with  astonishing  rapidity ;  commencing 
in  the  leg,  it  may  reach  the  trunk  within  twelve  hours.  At  the 
onset  of  the  disease  there  may  be  shivering,  or  more  rarely  a  distinct 
rigor,  accompanied  by  a  rise  of  temperature  and  marked  con- 
stitutional disturbance  due  to  the  absorption  of  toxines  from  the 
decomposing  and  infected  tissues.  Later  on  the  temperature  may 
fall  below  the  normal.  The  general  symptoms  are  of  the  asthenic 
type ;  there  is  marked  nervous  prostration  with  delirium,  deepening 
into  coma  and  death  within  two  or  three  days  of  the  onset. 

Prognosis. — The  prognosis  is  extremely  serious,  especially 
if  the  disease  approaches  the  trunk ;  the  great  majority  of  cases 
die. 

Treatment. — Preventive. — All  wounds  which  have  been  lacer- 
ated, contused,  or  contaminated  with  filth  must  be  thoroughly  cleaned 
with  1-20  carbolic  acid.  They  must  be  enlarged  if  necessary,  and 
the  deeper  parts  reached  by  syringing,  the  syringe  being  armed  with 
a  piece  of  elastic  tubing  which  can  be  insinuated  among  the  torn 
tissues.  If  mud  has  been  ground  into  the  lacerated  tissues  the  part 
should  be  cut  away  with  scissors.  Ample  provision  must  be  made 
for  the  escape  of  discharge,  and  rigid  antisepsis  observed. 

Curative. — Early  and  high  amputation  is  the  only  treatment 
offering  a  chance  of  success.  The  limb  must  be  removed  well 
above  the  blush,  otherwise  the  incisions  will  pass  through  diseased 
connective  tissue.  After  amputation  the  flaps  should  be  examined 
and  any  oedematous  and  discoloured  connective  tissue  must  be 
removed  with  scissors ;  unless  this  be  done  the  disease  will  continue 


122  MANUAL  OF   SURGERY  chap. 

spreading.     The  stump  should  be  thoroughly  cleansed  with  1-500 
mercury  solution. 

Although  amputation  is  the  only  remedy,  it  is  a  desperate 
resource,  for  the  gangrene  may  and  not  infrequently  does  return  in 
the  flaps ;  even  should  this  not  occur,  the  shock  of  the  operation 
may  prove  fatal  to  the  patient  in  his  critical  condition.  After  the 
operation  opium  should  be  given  and  a  stimulating  plan  of  treat- 
ment adopted.  Tubby  has  recorded  a  case  in  which  amputation  of 
the  arm,  followed  by  the  injection  of  anti-streptococcus  serum,  was 
successful  in  spite  of  the  fact  that  the  disease  had  actually  spread 
to  the  trunk  before  the  amputation.  In  this  case  the  bacillus  of 
malignant  oedema  was  not  discovered,  but  the  streptococcus  longus 
was  abundant. 


CUTANEOUS    ERYSIPELAS 

Under  the  term  erysipelas  most  surgical  writers  describe  three 
conditions:  (i)  cutaneous  erysipelas,  (2)  cellulo-cutaneous  or  phleg- 
monous erysipelas,  and  (3)  cellulitis.  If  we  are  prepared  to  admit  that 
these  are  all  due  to  the  same  organism,  the  different  clinical  effects 
being  dependent  upon  the  conditions  under  which  it  acts,  this 
classification  is  justifiable  and  right ;  but  it  would  appear  that  the 
cutaneous  form — erysipelas  proper — is  dependent  upon  a  specific 
micro-organism,  whereas  the  other  two  conditions  are  caused  by 
ordinary  pyogenic  organisms  or  by  mixed  infection. 

Fehleisen's  streptococcus  erysipelatis  is  identical  in  appearance 
and  in  its  behaviour  to  stains  and  culture  media  with  streptococcus 
pyogenes,  and  many  assert  that  these  organisms  are  one.and  the  same. 
Similarity  in  these  respects  does  not,  however,  necessarily  imply 
identity  of  species,  and  Fehleisen  claims  that  neither  is  the  organism 
of  cutaneous  erysipelas  capable  of  inducing  cellulo-dermatitis  or 
cellulitis,  nor  can  cutaneous  erysipelas  be  induced  by  the  strep- 
tococcus pyogenes.  These  observations  are,  however,  disputed  by 
other  authorities,  who  claim  to  have  induced  all  three  diseases 
by  the  same  poison.  Clinically,  the  occurrence  of  suppuration  in 
cellulo-dermatitis  and  cellulitis  and  its  absence  in  cutaneous  ery- 
sipelas offers  a  striking  contrast,  but  it  must  be  remembered  that 
the  same  organism  may  or  may  not  induce  suppuration  according 
to  circumstances.  This  clinical  difference  may  depend  on  the 
greater  virulence  of  the  organism  at  any  given  time,  or,  what  amounts 
to  the  same  thing,  on  the  lessened  resistance  of  the  tissues,  or  on  the 
seat  of  inoculation.       Mecrovitch,  who  regards  the  streptococcus 


VII  CUTANEOUS   ERYSIPELAS  123 

erysipelatis  as  identical  with  streptococcus  pyogenes,  says  that  if  the 
organism  be  injected  into  the  muscular  planes,  it  induces  diffuse 
suppuration  ;  if  into  joints,  suppurative  synovitis  ;  and  if  into  the 
peritoneal  cavity,  serous  peritonitis  which  may  become  purulent. 
He,  moreover,  regards  erysipelas  as  a  general  disease,  and  asserts 
that  it  only  remains  local  so  long  as  the  organisms  can  be  dealt  with 
by  the  local  phagocytes  ;  when  these  prove  inefficient,  the  organisms 
enter  the  blood-stream,  and  he  claims  to  have  proved  that  they  may 
pass  to  the  foetus  through  the  maternal  blood.  Cases  of  intra-uterine 
erysipelas  have  been  recorded  by  others. 

Meerovitch  has  succeeded  in  obtaining  from  cultures  on  raw- 
meat  a  toxic  alkaloid  proving  fatal  to  dogs. 

In    cutaneous    erysipelas,   cellulo-dermatitis,  and   cellulitis,   the 


Fig.  28. — Section  of  skin  at  the  spreading  margin  of  the  redness  in  erysipelas.  A  lymphatic 
vessel  is  seen  containing  micrococci,  which  are  also  spreading  into  the  tissues  around. 
(AVatson  Cheyne,  from  a  photograph  by  Koch,  X  700.) 

disease  spreads  by  the  lymphatics,  and  excites  inflammation  of  the 
vessel  walls,  coagulation  of  their  contents,  and  lymphadenitis.  In 
cutaneous  erysipelas  the  organisms  are  found  in  the  spreading 
margin  of  the  blush  and  slightly  in  advance  of  it,  but  not  in  that 
part  over  which  the  margin  has  passed  ;  in  cellulitis  and  phlegmon 
they  are  present  in  all  parts.  Most  authorities  agree  that  the  blood 
is  not  inoculable,  and  Fehleisen,  having  induced  cutaneous  erysipelas 
in  a  rabbit's  ear  by  inoculation,  arrested  all  constitutional  symptoms 
by  amputating  the  organ  beyond  the  blush. 

The  local  effects  are  due  to  the  caustic  action  of  the  toxines, 
the  constitutional  symptoms  to  their  absorption.  At  present  it 
must  remain  uncertain  whether  Fehleisen's  streptococcus  erysipelatis 
is  identical  with  the  streptococcus  pyogenes,  and  whether  all  three 
conditions  usually  described  as  erysipelas  are  identical  as  regards 
etiology ;  but  it  appears  probable  on  the  evidence  that  we  should 
attribute  cutaneous  erysipelas  to  a  distinct  organism — S.  erysipelatis; 


124  MANUAL  OF  SURGERY  chap. 

cellulitis  to  S.  pyogenes  and  other  pyogenic  organisms ;  and  cellulo- 
dermatitis  to  mixed  infection  of  S.  erysipelatis  and  S.  pyogenes. 

Etiolog"y. — In  all  cases  the  streptococcus  erysipelatis  gains 
entry  through  a  wound,  which  may  be  so  small  as  to  be  readily 
overlooked,  and  hence  it  has  been  asserted  that  erysipelas  may  arise 
idiopathically.  Minute  cracks,  scratches,  or  eczematous  patches  are 
often  the  seats  of  infection  about  the  face ;  these  are  frequently 
situated  near  the  angle  of  the  mouth,  ala  of  the  nose,  inside  the 
nostril  or  behind  the  ear.  Any  part  of  the  body  may  be  affected, 
but  the  head,  neck,  and  especially  the  face  are  the  favourite  seats. 
New-born  children  may  be  infected  through  the  umbilicus.  In- 
dividual susceptibility  is  marked ;  and  although  one  attack  appears 
to  confer  immunity,  this  is  of  a  very  temporary  nature,  and  repeated 
attacks  are  common. 

Bad  hygienic  surroundings,  chronic  alcoholism,  diabetes,  kidney- 
disease,  or  impairment  of  the  general  health  from  any  cause  are 
important  etiological  factors.  Erysipelas  may  assume  a  distinctly 
epidemic  character,  and  is  more  common  in  spring  and  autumn  and 
in  damp  and  cold  weather. 

Constitutional  symptoms  are  present  a  few  hours  before 
the  appearance  of  the  blush.  The  onset  is  sudden  and  marked 
by  chills  or  a  distinct  rigor,  the  temperature  rising  to  103°- 
106°  F.  Frontal  headache,  nausea,  vomiting,  furred  tongue,  con- 
stipation, pains  in  the  limbs,  and  general  malaise  are  all  present. 
The  pulse  is  rapid,  full  and  soft,  and  as  nervous  prostration 
sets  in,  its  rapidity  increases  and  it  becomes  feeble  and  small. 
Nervous  prostration  comes  on  rapidly  and  is  often  severe ;  delirium 
sets  in  at  night,  the  tongue  is  dry  and  brown,  the  lips  loaded  with 
sordes,  and  constipation  may  be  succeeded  by  offensive,  sometimes 
bloody  diarrhoea.  Death  may  ensue  from  exhaustion  or  from  some 
intercurrent  mischief,  especially  pneumonia. 

The  local  signs  appear  within  a  few  hours  of  the  constitutional 
disturbance.  There  is  general  superficial  tenderness  and  tingling, 
with  a  feeling  of  stiffness  of  the  skin,  which  pits  slightly  on  pressure. 
The  affected  area  is  covered  with  a  vivid  red  blush  having  a  well- 
defined,  slightly  raised  margin,  in  and  a  little  beyond  which  the 
streptococci  are  abundantly  found  (Fig.  28,  p.  123),  but  they  are 
absent  elsewhere. 

The  blush  quickly  disappears  on  pressure  and  as  quicVry  returns ; 
it  disappears  at  death.  Should  recovery  take  place,  the  blush  is  replaced 
byyellowish  discoloration;  branny  desquamation  follows,  accompanied 
by  a  falling  of  the  hair,  which,  however,  quickly  grows  again. 


VII  CUTANEOUS   ERYSIPELAS  125 

The  lymphatics  running  from  the  parts  are  engorged  and  in- 
flamed, and  the  neighbouring  glands  are  swollen  and  tender. 
Suppuration  does  not  occur,  but  loose  bullce  containing  clear  or 
sanious  serum  often  form  on  the  surface.  The  bullae  may  burst,  or 
dry  up  and  form  dry  scabs.  There  is  considerable  exudation  into  the 
subcutaneous  connective  tissue,  which  does  not,  however,  participate 
in  the  inflammatory  process.  The  degree  of  swelling  thus  induced 
depends  on  the  laxity  of  the  tissues;  in  the  face  it  is  very  marked, 
closing  the  eyes  and  causing  the  most  unsightly  appearance.  If  there 
be  a  wound  of  any  appreciable  size,  healing  is  arrested  ;  the  granula- 
tions are  pale  and  flabby  and  undergo  atrophy,  and  the  surface, 
dry  and  glazed  at  first,  becomes  bathed  in  pus  as  inflammation  sets  in. 

Diagnosis. — Simple  erythema  may  readily  be  diagnosed  from 
erysipelas  by  the  absence  of  fever  and  general  disturbance,  and  by 
the  redness  being  diffuse  and  patchy,  and  unaccompanied  by 
tenderness  or  pitting  on  pressure. 

Prognosis. — Cutaneous  erysipelas  is  not  a  dangerous  affection 
in  otherwise  healthy  patients,  recovery  taking  place  in  from  ten  to 
twenty  days.  The  aged,  those  addicted  to  alcohol,  and  the  subjects 
of  general  disease — especially  diabetes  and  renal  mischief — are 
liable  to  suffer  severely  and  may  die.  Cardiac  failure,  as  evidenced 
by  the  rapidity  and  feebleness  of  the  pulse,  high  fever,  persistent 
delirium,  and  profuse  diarrhoea  are  ominous  signs. 

Erysipelas  about  the  orbit  or  in  connection  with  scalp  wounds 
may  spread  to  the  meninges,  and  oedema  of  the  glottis  is  to  be 
feared  when  the  fauces  are  attacked.  Hypostatic  pulmonary  con- 
gestion and  pneumonia  are  serious  and  not  uncommon  complications, 
especially  in  old  people.  Recurrence  of  erysipelas  is  common ; 
after  repeated  attacks  (especially  in  the  face)  the  skin  becomes 
thickened,  hard,  and  inelastic,  and  the  change  may  give  rise  to 
marked  and  permanent  alteration  in  the  personal  appearance. 

Treatment. — The  patient  must  be  rigidly  isolated.  Constitu- 
tional treatment  must  be  directed  to  preventing  and  combating  the 
prostration  induced  by  the  disease.  The  strength  must  be  main- 
tained by  good,  nutritious  diet,  with  stimulants  :  port  wine,  cham- 
pagne, and  brandy  being  the  best.  The  action  of  the  skin,  kidneys, 
and  bowels  must  be  regulated.  Ammonia.,  quinine,  and  iron  are 
the  most  useful  drugs.  Iron  is  thought  by  some  to  have  a  specific 
effect  and  may  be  given  in  half-drachm  doses  of  the  tincture  every 
four  hours.  Aconite,  pilocarpine,  and  salicylate  of  soda  have  their 
advocates.  Numerous  local  applications  have  been  vaunted  by 
some,  condemned  by  others.     In  facial  erysipelas  the  parts  must  be 


126  MANUAL  OF   SURGERY  chap. 

freely  dusted  with  starch-powder  or  oxide  of  zinc,  and  should  be  kept 
from  the  air  by  a  thick  mask  of  cotton  wadding.  Some  surgeons 
speak  highly  of  the  application  of  a  30  per  cent  solution  of  tincture 
of  iron,  which  should  be  freely  rubbed  into  the  skin ;  others 
recommend  the  use  of  the  solid  nitrate  of  silver  to  the  margin  of  the 
blush  ;  but  it  seems  very  doubtful  if  either  of  these  methods  has  any 
beneficial  influence,  either  in  arresting  the  spread  of  the  disease  or 
of  a  curative  nature.  German  surgeons  extol  the  virtues  of  equal 
parts  of  ichthyol  and  vaseline  rubbed  into  the  skin  twice  daily,  and 
claim  that  it  cuts  short  the  disease  in  three  days.  A  10  per  cent 
solution  of  ichthyol  in  collodion,  painted  over  the  blush  and  some 
distance  beyond  it,  is  also  recommended.  Koch  advises  that  the 
parts  and  the  skin  round  should  be  anointed  twice  daily  with  creohn 
I,  iodoform  4,  and  lanolin  10  parts;  while  Rosenbach  applies  daily 
a  5  per  cent  solution  of  carbolic  acid  in  absolute  alcohol. 
Hallopean  asserts  that  the  disease  may  be  cured  in  four  days  by 
applying  cotton  wadding  soaked  in  5  per  cent  solution  of  sali- 
cylate of  soda.  Before  any  local  application  is  applied  the  parts 
should  be  thoroughly  cleaned  with  i:  1000  mercury  solution. 

Kroell,  Woelfler,  and  others  adopt  the  so-called  mechanical 
treatment  with  the  view  of  preventing  the  organisms  passing  along 
the  lymphatics.  The  part  is  encircled  by  a  bandage  or  adhesive 
strapping  about  2  cm.  beyond  the  blush,  which  does  not  spread 
beyond  it ;  the  encircling  band  should  be  retained  for  three  or  four 
days  after  the  temperature  has  fallen  to  the  normal. 

In  view  of  the  fact  that  the  streptococci  are  confined  to  the 
margin  of  the  blush  and  about  2  cm.  beyond  it,  and  that  it  is  readily 
killed  by  1-30  carbolic  solution,  Hueter  advises  subcutaneous 
injection  of  the  latter  in  the  area  indicated ;  numerous  small  punc- 
tures must  be  made,  and  it  must  be  borne  in  mind  that  poisonous 
effects  may  follow  the  injection  of  large  quantities.  As  a  modifica- 
tion of  this  plan,  Kraske  first  scarifies  the  skin  at  the  margin  of  the 
blush  and  then  rubs  in  the  carbolic  solution. 

If  bullae  form  the  fluid  may  be  evacuated,  but  the  epithelium, 
which  serves  as  a  protection  to  the  papillae,  should  not  be  removed. 

Any  wound  which  may  be  present  should  be  thoroughly  cleaned 
and  free  drainage  must  be  provided. 

An  antitoxin  serum  has  been  prepared  by  Marmorek,  injection 
of  which  is  said  to  bring  about  cure,  even  in  severe  cases ;  at  present 
the  cases  reported  are  not  sufficiently  numerous  to  afford  us  grounds 
for  speaking  positively  as  to  the  results  of  this  treatment.  It  is, 
however,  worthy  of  trial  (see  p.  215). 


VII  CELLULO-DERMATITIS  127 

During  convalescence  the  diet  should  be  generous  and  should 
include  stout  or  port  wine.  Tonics,  especially  the  mineral  acids 
and  vegetable  bitters  with  iron  and  quinine,  and  plenty  of  fresh 
air,  are  the  best  means  of  combating  the  anaemia  and  weakness  left 
by  the  disease. 

CELLULO-DERMATITIS    (CELLULO-CUTANEOUS  OR 
PHLEGMONOUS    ERYSIPELAS) 

Etiology. — As  stated  on  p.  122,  there  are  grounds  for  believing 
that  this  disease  is  distinct  from  erysipelas,  and  is  probably  depend- 
ent on  mixed  infection  with  the  streptococcus  erysipelatis  and 
streptococcus  pyogenes ;  but  at  present  opinions  conflict  and  no 
positive  proof  on  either  side  is  forthcoming. 

Cellulo-dermatitis  attacks  recent  wounds,  usually  poisoned  from 
the  first,  which  implicate  the  subcutaneous  tissue  or  penetrate  the 
intermuscular  planes.  It  is  not  highly  contagious,  and  if  due  care 
be  taken  to  prevent  inoculation  by  means  of  sponges,  instruments, 
the  hands,  etc.,  there  is  no  danger  of  the  disease  spreading  among 
surgical  patients.      It  especially  attacks  drunkards  and  the  cachectic. 

Local  signs. — The  inflammation  begins  in  the  subcutaneous 
tissue  and  quickly  implicates  the  skin.  The  connective  tissue  is 
infiltrated  with  exudation,  which  causes  great  oedema  and  swelling, 
and  the  parts  pit  readily  on  pressure.  There  is  considerable  burn- 
ing, throbbing  pain  from  pressure  on  the  nerves.  The  skin  is  tense 
and  covered  by  a  deep  red  blush,  wanting,  however,  the  distinct 
margin  seen  in  cutaneous  erysipelas.  The  lymphatic  vessels  and 
glands  may,  but  do  not  necessarily,  participate  in  the  process. 
With  the  increase  of  the  exudation  tension  becomes  greater ;  the 
natural  folds  and  wrinkles  of  the  skin  are  lost,  it  becomes  brawny, 
smooth,  shiny,  and  of  a  dusky,  livid  colour.  The  disease  spreads 
most  rapidly  on  the  inner  aspect  of  the  limb,  where  the  cellular 
tissue  is  most  abundant  and  loose. 

Diffuse  suppuration  with  sloughing  of  the  connective  tissue  and 
localised  gangrene  of  the  skin,  preceded  by  the  formation  of  blebs, 
occurs  in  from  three  to  five  days  of  the  onset.  The  amount  of 
destruction  varies  with  the  intensity  of  the  process  and  the  prompt- 
ness of  treatment.  If  incisions  are  made  early  tension  is  quickly 
relieved,  the  pain  diminishes  or  disappears,  and  sloughing  of  the 
skin  is  averted  or  at  least  reduced  to  a  minimum.  Unless  the 
original  wound  has  opened  the  deep  fascia,  the  intermuscular  planes 
are  not  involved ;  but  in  such  a  case  the  destruction  may  be  very 


128  MANUAL  OF  SURGERY  chap. 

widespread,  the  muscles,  nerves,  and  vessels  being  more  or  less 
completely  dissected  out.  Even  in  the  worst  cases  hnsmorrhage  is 
a  rare  event,  since  the  large  vessels  escape  destruction  and  the 
smaller  ones  are  thrombosed  as  the  result  of  inflammation  of  their 
walls. 

If  an  incision  be  made  into  the  brawny  area  it  gapes  widely, 
disclosing  the  connective  tissue  infiltrated  with  ashen-gray  or  puru- 
lent exudation,  and  large  yellow  sloughs  bathed  in  pus. 

Should  the  part  recover,  the  sloughs  slowly  separate,  and  heal- 
ing takes  place  by  granulation.  The  new  scar-tissue  may  cause 
considerable  impairment  of  motion  by  matting  together  the  muscles, 
should  their  cellular  planes  have  been  affected. 

Constitutional  symptoms. — High  fever,  with  asthenic 
symptoms  and  prostration,  is  the  rule.  The  fever  may  reach  105°  F. 
and  be  ushered  in  by  chills  or  a  rigor.  Headache,  anorexia,  thirst, 
vomiting,  and  delirium  at  night  are  present.  Sometimes — especially 
in  drunkards — delirium  is  noisy  and  constant,  and  delirium  tremens 
may  supervene.  The  tongue  is  furred,  and  later  on  dry,  cracked, 
and  loaded  with  sordes. 

Constipation  is  usual,  but  diarrhoea  sets  in  in  bad  cases.  The 
pulse  is  at  first  rapid  and  full,  but  becomes  small  and  feeble  as 
nervous  prostration  deepens.  In  fatal  cases  typhoid  symptoms 
make  their  appearance  and  coma  precedes  death. 

Prognosis. — The  prognosis  of  cellulo-dermatitis  is  always  grave, 
since  it  occurs  chiefly  in  drunkards  and  those  broken  down  by 
disease.  It  is  most  serious  when  attacking  the  head  and  neck  and 
other  regions  rich  in  cellular  tissue,  and  when  it  spreads  to  deep  parts, 
e.g.  the  mediastinum,  where  it  is  beyond  the  reach  of  surgical  treat- 
ment. High  fever,  persistent  delirium,  diarrhoea,  and  cardiac 
failure  are  serious  signs.  Hypostatic  congestion  and  pneumonia  or 
general  septic  infection  may  prove  fatal. 

The  prognosis  as  to  the  ultimate  utility  of  the  part  depends  upon 
the  extent  and  depth  of  the  process.  Matting  of  the  tendons  and 
muscles  may  be  more  or  less  permanent,  or  the  destruction  may  be 
so  widespread  that  amputation  is  the  only  resource. 

Treatment. — Although  isolation  of  the  patient  is  not  necessary, 
every  care  must  be  taken  that  the  contagion  is  not  spread  from 
patient  to  patient  in  a  hospital  ward. 

The  general  treatment,  with  the  exception  of  the  administration 
of  iron,  is  practically  that  given  under  cutaneous  erysipelas  (p.  125). 
The  wound  should  be  thoroughly  cleaned,  efficient  drainage  pro- 
vided, and  tension  relieved  by  the  removal  of  any  sutures  which 


VII  CELLULITIS   (CELLULAR   ERYSIPELAS)  129 

may  have  been  used.  Moist  heat,  appHed  by  hot  boracic  fomenta- 
tions, or  by  immersion  in  the  hot  boracic  bath,  may  cut  short  the 
process  and  avert  suppuration.  The  part  should  be  elevated  if 
possible. 

As  soon  as  pitting  gives  place  to  brawniness,  tension  must  be 
relieved  by  free  incisions.  These  should  be  numerous  and  of  suffi- 
cient length,  and  made,  if  possible,  in  situations  devoid  of  large 
veins,  as  the  loss  of  blood  may  be  a  serious  matter  in  a  debilitated 
patient.  Any  divided  vessels  should  be  ligatured  and  profuse  oozing 
arrested  by  temporary  plugging  with  antiseptic  gauze.  If  the  wound 
and  tissues  exposed  by  the  incisions  be  swabbed  over  with  pure 
carbolic  acid,  the  further  spread  of  the  mischief  is  arrested.  The 
separation  of  the  sloughs  must  be  encouraged  by  the  continued 
application  of  heat  and  moisture.  When  granulation  is  fully 
established  the  wounds  should  be  dressed  with  some  simple  lotions, 
such  as  boracic  acid  or  red  wash.  During  the  healing  process, 
gentle  passive  motion  and  massage  will  do  much  to  obviate  matting 
of  the  tendons  and  muscles,  and  to  restore  the  suppleness  of  the 
parts. 

If  the  destruction  of  the  limb  is  so  great  as  to  make  amputation 
advisable,  this  should  not  be  performed  until  the  disease  has  been 
arrested  and  the  patient  has  so  far  recovered  from  its  effects  that 
he  can  stand  the  shock  of  the  operation. 

Treatment  with  anti-streptococcus  serum  has  apparently  been 
beneficial  (see  p.  215). 

CELLULITIS    (cellular    ERYSIPELAS) 

Etiology. — The  organism  usually  present  is  the  streptococcus 
pyogenes,  but  it  is  practically  certain  that  this  is  by  no  means  the 
only  one  capable  of  inducing  cellulitis.  The  disease  is  especially  likely 
to  occur  in  poisoned  wounds,  and  may  follow  the  sting  or  bite  of  a 
poisonous  insect.  Drunkards  and  cachectic  patients  are  especially 
liable  to  attack. 

Local  signs. — The  pathological  and  clinical  features  of  cellulitis 
are  similar  to  those  met  with  in  cellulo-dermatitis,  the  only  difference 
being  that  in  the  latter  condition  the  skin  is  equally  affected  with 
the  subcutaneous  tissue,  whereas  in  cellulitis  it  is  secondarily  involved 
from  interference  with  its  blood  supply  by  means  of  the  pressure 
exercised  on  the  vessels  by  the  inflammatory  exudate. 

Suppuration  is  less  common  in  cellulitis  than  in  cellulo-derma- 
titis,  and   the   former  may  occur  rt  a  distance   from  the    seat   of 

VOL.  I  K 


I30  MANUAL   OF   SURGERY  chap. 

inoculation.  In  some  cases  cellulitis  spreads  rapidly,  in  others  it 
remains  more  limited  and  is  quickly  subdued  by  treatment,  or 
should  suppuration  occur,  the  pus  remains  localised. 

The  constitutional  symptoms  are  similar  to  those  of 
cellulo- dermatitis,  but  do  not  usually  run  so  severe  a  course, 
especially  if  suppuration  is  averted. 

Prognosis. — Cellulitis  is  not  usually  dangerous  to  life  unless  it 
occurs  in  a  dangerous  situation.  The  prognosis  depends  chiefly  on 
the  intensity  of  the  process  and  the  state  of  health  of  the  patient. 

Treatment. — That  of  cellulo-dermatitis. 


CELLULITIS    IN    SPECIAL    REGIONS 

Cellulitis  of  the  scalp  may  complicate  dirty  and  ill-drained 
wounds.  The  inflammation  occurs  beneath  and  is  limited  by  the 
cranial  aponeurosis.  There  is  considerable  swelling  and  great  pain, 
with  puffiness  and  bagginess  of  the  tissues.  Extension  to  the  men- 
inges may  occur  through  the  emissary  veins  or  through  a  fracture, 
and  hence  the  prognosis  is  grave.  The  treatment  consists  in  re- 
moval of  the  hair,  the  employment  of  antiseptics,  and  incisions  made 
parallel  to  and  between  the  main  vessels  and  nerves,  coupled  with 
the  application  of  hot  boracic  fomentations. 

Cellulitis  of  the  orbit  may  result  from  a  wound  or  from  sup- 
purative panophthalmitis.  There  is  considerable  pain,  with  swelling 
and  closure  of  the  lids,  chemosis  of  the  conjunctiva,  and  proptosis. 
Unless  tension  be  relieved  by  timely  incisions,  the  inflammation 
may  extend  backwards  through  the  sphenoidal  fissure,  or  by  the 
ophthalmic  veins  to  the  cavernous  sinus.  The  lid  should  be  raised, 
a  free  incision  made  between  it  and  the  globe  into  the  cellular 
tissue,  and  hot  boracic  fomentations  applied. 

Cellulitis  of  the  neck — Angina  Ludovici. — Cellulitis  of  the 
deep  planes  of  the  neck  may  result  from  ulceration  or  sloughing 
about  the  mouth  or  throat,  or  from  extension  of  a  suppurative  pro- 
cess in  connection  with  middle  ear  disease  or  dental  caries.  It 
may  also  occur  in  connection  with  strumous  glands.  The  inflam- 
mation usually  begins  at  the  upper  part  of  the  neck  and  extends 
downwards.  In  the  worst  cases  it  may  spread  to  the  superior 
mediastinum.  Owing  to  the  density  of  the  deep  cervical  fascia  the 
tension  and  pain  are  severe,  and  the  former  may  cause  difficulty  in 
swallowing  and  respiration.  Extension  to  the  larynx  and  oedema 
of  the  glottis  constitutes  a  formidable  danger.  Prompt  incisions 
must    be    made    and    so    placed    that    no    important    structure  is 


VII  RABIES   (HYDROPHOBIA)  131 

damaged.  Laryngotomy  may  be  required  if  the  disease  spreads  to 
the  larynx. 

Cellulitis  sometimes  begins  in  the  cellular  tissue  round  the  base 
of  the  tongue,  and  in  such  cases  the  swelling  is  centrally  placed 
and  symmetrical  beneath  the  jaw.  There  is  considerable  danger 
of  extension  to  the  larynx,  causing  sudden  and  fatal  oedema ;  this 
may,  however,  usually  be  averted  by  an  early  and  deep  median 
incision. 

Pelvic  cellulitis  most  usually  occurs  in  connection  with  abor- 
tion or  parturition.  It  may  complicate  gonorrhoea  or  follow  instru- 
mentation of  the  uterus,  and  may  also  occur  after  operations 
about  the  perineum.  In  women  the  poison  usually  gains  access 
through  abrasions  or  wounds  of  the  cervix  uteri ;  the  process 
begins  in  the  peri-uterine  connective  tissue,  and  spreads  by  means 
of  the  rich  lymphatic  network  of  the  pelvis.  It  is  often  complicated 
by  pelvic  peritonitis.  Pelvic  cellulitis  occasionally  occurs  in  men, 
especially  in  connection  with  operations  about  the  pelvic  viscera. 

There  are  the  usual  signs  of  fever.  Pain  above  the  pubes  is 
complained  of,  often  referred  to  one  or  other  side,  and  on  vaginal 
examination  an  indurated,  acutely  tender  patch  is  felt,  displacing 
and  fixing  the  uterus.  Suppuration  does  not  usually  occur ;  should 
it  do  so  the  patch  softens,  the  general  symptoms  deepen,  and  the 
fever  becomes  remittent.  The  abscess  may  burst  into  the  vagina 
or  rectum,  open  on  the  groin,  or  escape  by  the  sacro-sciatic  notch. 
Very  rarely  the  pelvic  abscess  bursts  into  the  bladder  or  general 
peritoneal  cavity.  Unless  great  care  be  taken  to  prevent  it,  putre- 
faction of  the  contents  of  the  abscess  may  occur  and  seriously  add 
to  the  patient's  danger.  It  sometimes  happens  that  a  dense  mass 
of  cicatricial  tissue  is  left,  which  by  involving  the  ureter  may  lead 
to  secondary  hydronephrosis. 

Treatment. — To  promote  absorption  and  prevent  suppuration 
the  patient  must  be  kept  at  rest,  with  hot  fomentations  applied 
to  the  hypogastrium.  The  bowels  should  be  kept  acting,  and  warm, 
antiseptic  vaginal  douches  used  frequently.  If  suppuration  occurs 
the  abscess  must  be  freely  opened  and  drained. 

RABIES    (hydrophobia) 

Etiology. — Rabies  is  always  communicated  from  a  rabid  animal 
by  inoculation,  and  never  arises  spontaneously.  It  is,  doubtless, 
dependent  on  a  m.icro- organism ;  but  none  has  so  far  been 
discovered.      The    poison    is    chiefly   present    in    the    saliva    and 


132  MANUAL  OF   SURGERY  chap. 

central  nervous  system,  but  exists  in  all  tissues  and  secretions. 
It  is  attenuated  by  moderate,  and  destroyed  by  prolonged  desicca- 
tion. It  by  no  means  follows  that  a  bite  from  a  rabid  animal  is 
followed  by  rabies ;  indeed,  about  50  per  cent  escape.  This  im- 
munity depends  chiefly  upon  the  situation  and  extent  of  the  wound. 
Bites  on  the  face,  hands,  or  exposed  parts,  especially  if  multiple,  are 
more  dangerous  than  those  on  protected  parts,  where  the  injuries 
are  not  so  extensive,  and  where  entrance  of  the  saliva  is  in  some 
measure  prevented  by  the  clothes.  Individual  immunity  may  also 
have  some  bearing  on  the  point.  Dogs,  wolves,  jackals,  foxes,  and 
cats  are  the  animals  chiefly  subject  to  rabies ;  but  it  may  be  com- 
municated to  all — even  to  birds.  In  this  country  dogs  are  the 
usual  source  of  infection. 

Symptoms. — The  incubative  stag'e  varies  within  wide  limits. 
The  symptoms  generally  make  their  appearance  during  the  second 
month  after  inoculation,  but  may  be  postponed  for  as  long  as  two 
years.  The  wound,  which  has  usually  soundly  healed,  and  has  given 
no  trouble,  often  becomes  the  seat  of  prodromal  pains  and  tinglings 
which  sometimes  radiate  along  the  nerves.  The  scar  may  reopen, 
or  be  studded  with  vesicles.  The  patient  is  restless,  depressed,  and 
apprehensive  of  coming  evil.  He  is  often  reserved  about  the  fact 
of  inoculation,  but  shows  a  repugnance  to  fluid,  with  perhaps  diffi- 
culty in  swallowing  it,  which  he  tries  to  overcome.  Hydrophobia 
in  a  marked  form  is  not  yet  present.  There  is  anorexia  with 
vomiting.  This  prodromal  stage  may  be  absent  or  may  last  for 
from  one  to  seven  days ;  it  suddenly  passes  into  the  fully  developed 
disease. 

The  acute  symptoms  begin  by  violent  convulsions  of  the  deglu- 
tition and  respiratory  muscles.  The  convulsions  are  spasmodic,  not 
tetanic ;  they  may  be  momentary,  or  may  last  for  some  minutes,  and 
are  repeated  at  longer  or  shorter  intervals,  the  spasm  being  fre- 
quently determined  by  some  trivial  cause,  such  as  a  noise  (especially 
the  sound  of  running  water),  the  sight  of  water,  a  slight  draught,  or 
a  mere  touch  of  the  skin.  At  the  onset  of  an  attack,  the  sudden 
contraction  of  the  diaphragm  and  muscles  of  respiration  may  occa- 
sion a  cry  or  a  series  of  short,  quick,  sobbing  sounds. 

During  the  paroxysm  the  patient's  appearance  is  most  distressing - 
and  terrifying  to  the  bystanders.  He  suddenly  springs  up  in  bed, 
clutches  at  his  throat,  and  tosses  his  arms  and  head  about ;  the  face 
is  pale  and  terror-stricken,  the  pupils  dilated,  and  the  skin  often 
bathed  in  sweat.  Viscid  saliva  accumulates  in  and  dribbles  from 
the  mouth.      This  causes  the  patient  much  annoyance,  and  in  his 


VII  RABIES   (HYDROPHOBIA)  133 

efforts  to  get  rid  of  it  he  may  spit  it  in  all  directions,  and  on  his 
attendants.      This  saliva  is  contagious. 

Painful  erections,  satyriasis,  and  emissions  are  common.  The 
most  marked  and  predominant  symptom  is  hydrophobia,  and  from 
this  fact  the  disease  takes  its  name.  In  the  early  stages  the  patient 
may  make  heroic  efforts  to  overcome  his  dread  of  water ;  but  as  soon 
as  the  fluid  touches  his  lips,  in  spite  of  his  thirst  he  flings  the  glass 
from  him  and  a  paroxysm  comes  on.  The  sound  of  running  water, 
or  the  mere  sight  of  fluid,  is  equally  disturbing.  In  rare  cases  hydro- 
phobia is  absent,  so  that  the  patient  will  make  every  endeavour  to 
assuage  his  thirst,  but  this  quite  ineffectually,  owing  to  the  super- 
vention of  spasm. 

The  mental  balance  is  much  disturbed.  In  all  cases  there  is 
evident  terror,  extreme  restlessness,  and  mental  agitation.  The 
patient  talks  volubly,  quickly,  and  with  marked  agitation  ;  he  fre- 
quently shouts  and  cries  out,  and  is  suspicious  of  all  who  come  near 
him.  Sometimes  he  constantly  refers  to  the  animal  that  bit  him, 
and  may  himself  try  to  bite  those  around  him.  Acute  mania  of  a 
violent  form  is  sometimes  present.  The  mental  excitement  may 
temporarily  subside  and  give  place  to  quietude  and  rationalism,  only 
to  recur  with  greater  violence. 

The  temperature  may  be  normal  throughout,  or  rise  one  or  two 
degrees  ;  the  pulse,  after  a  short  time,  is  feeble  and  rapid.  Towards 
the  end  general  muscular  exhaustion  becomes  marked,  and  the 
patient  may  develop  the  paralytic  signs  met  with  in  the  "  dumb  " 
rabies  of  animals. 

Sudden  death  may  ensue  from  cardiac  failure,  or  spasm  of  the 
glottis  and  suffocation. 

Diagnosis. — The  diagnosis  from  tetanus  is  easy.  In  that 
disease  the  incubative  period  is  short,  the  muscles  are  tetanised,  the 
intellect  remains  clear,  there  is  no  viscid  saliva  from  the  mouth,  and 
hydrophobia  is  absent. 

When  any  one  has  been  bitten  by  a  dog  supposed  to  be  rabid, 
the  animal  should  by  no  means  be  killed,  but  safely  secured,  and 
watched  for  weeks  if  necessary.  If  it  has  been  killed,  it  should,  if 
possible,  be  sent  to  an  institution  where  inoculation  may  be  employed 
to  confirm  the  diagnosis  of  rabies. 

Rabies  in  the  dog"  is  characterised  by  sudden  alteration  in  his 
temper  and  habits.  He  is  subject  to  paroxysms  of  fury,  snaps  at  his 
fellows  or  at  imaginary  objects,  and  bites  his  kennel,  straw,  or  chain  ; 
he  is  very  restless,  and  moves  about  in  an  aimless  way  regardless  of 
things  which  would  attract  his  attention  if  in  a  state  of  health  j  he 


134  MANUAL  OF   SURGERY  chap. 

is  languid  in  spite  of  his  restlessness,  and  hides  himself  away  in 
darkened  corners.  There  is  no  hydrophobia,  and  the  animal  will 
greedily  lave  his  muzzle  (dripping  tenacious,  and  highly  infective 
saliva)  in  water,  but  is  unable  to  drink.  He  rapidly  emaciates,  his 
appetite  is  perverted,  and  he  will  swallow  all  sorts  of  rubbish.  Ke 
is  generally  "  humped  up,"  with  his  back  curved  and  his  tail  drooped. 
His  cry  is  characteristically  ringing,  high-pitched,  and  croupy.  To- 
wards the  end  he  passes  into  the  paralytic  stage. 

Paralytic  or  dumb  rabies  may  be  present  from  the  first,  and  is 
characterised  by  paralysis  of  the  hind-quarters  and  of  the  jaw,  so 
that  the  dog  cannot  bite  or  bark ;  the  tongue  protrudes,  and  saliva 
dribbles  from  the  mouth.  The  animal  is  lethargic  and  quiet.  Death 
ensues  within  a  week 

Prognosis. — Rabies  Is  fatal  to  man  in  from  two  to  seven  days. 
Death  may  be  due  to  exhaustion  or  suffocation. 

Post-mortem  appearances. — The  chief  signs  met  with  in 
rabies  are  congestion  and  incipient  inflammation  of  the  pharynx, 
salivary  glands,  and  certain  parts  of  the  nervous  system.  In  the  spinal 
cord  and  medulla,  especially  about  the  deglutition  and  respiratory 
centres,  viz.  the  roots  of  the  glossopharyngeal,  vagus,  and  hypoglossal 
nerves,  there  is  congestion  of  the  vessels,  with  exudation  of  leucocytes 
round  their  sheaths  accompanied  by  minute  haemorrhages.  The 
nerve-ganglion  cells  are  degenerated. 

Treatment. — Preventive. — When  a  person  has  been  bitten  by 
an  animal  supposed  to  be  rabid,  he  should  without  delay  be  treated  by 
Pasteur's  inoculation  method.  Pending  this  the  wound,  which  may 
be  freely  sucked  by  the  patient,  should  be  thoroughly  cauterised,  or 
completely  excised.  The  "  simple  method  "  of  Pasteur  is  applicable 
to  all  cases  where  the  bite  has  been  through  the  clothes,  and  to 
slight  wounds  on  the  soft  parts.  The  "  intensive  "  method  is  advis- 
able in  more  severe  cases.  Two  inoculations  of  varying  strength 
are  made  daily  for  a  fortnight  or  more.  The  injections  are  made 
into  the  subcutaneous  tissue  of  the  loins  or  abdomen,  and  do  not 
give  rise  to  local  or  general  disturbance.  The  vaccine  is  prepared 
from  dried  pieces  of  the  spinal  cord  of  inoculated  rabbits.  The 
longer  these  have  been  desiccated  the  less  virulent  they  are,  and 
hence  the  dose  may  be  increased  by  using  cords  which  have  been 
dried  for  shorter  periods.  The  following  table  will  show  the  method 
of  treatment  on  each  successive  day  of  inoculation  : — 


VII 


RABIES   (HYDROPHOBIA) 


135 


Si.MFLE  Method. 

Intensive  Method. 

Days  of  Dr>'ing  the  Cord. 

Day  of  Treatment. 

Days  of  Drying  the  Cord. 

14               13 

I 

14         13         12         II 

12                II 

2 

10        9        8        7 

10                  9 

3 

6        6 

8            7 

4 

5 

6            6 

5 

5 

5 

6 

4 

5 

7 

3 

4 

8 

4 

3 

9 

3 

5 

10 

5 

5 

II 

5 

4 

12 

4 

4 

13 

4 

3 

14 

3 

3 

15 

3 

16 

Rest 

17 

Rest 

18 

5 

19 

4 

20 

3 

Each  injection  consists  of  5  c.cm.  of  spinal  cord  crushed  in 
2  c.cm.  of  sterile  beef-tea.  On  the  days  when  two  strengths  are 
given,  one  is  injected  in  the  morning,  the  other  and  stronger  in  the 
evening. 

Curative. — When  rabies  has  actually  come  on,  treatment  is  of 
little  avail,  but  the  intensive  method  should  if  possible  be  adopted. 
Mercurial  inunction  is  said  to  have  been  successful ;  but  more 
reliance  is  placed  on  curari,  physostigmine,  chloral,  morphia,  and 
chloroform.  The  two  last  may  be  used  to  quiet  the  patient  if  there 
is  much  mental  excitement,  but  chloral  is  most  efficacious  in  lessening 
the  spasm.  Curari  is  well  tolerated  by  rabid  patients,  and  may  be 
given  in  doses  of  one-eighth  of  a  grain  every  fifteen  or  twenty  minutes 
until  benefit  is  derived ;  but  care  must  be  taken  that  muscular  para- 
lysis is  not  induced,  or  the  breathing  will  stop.  The  patient  should 
be  kept  quiet  in  a  darkened  room,  and  all  causes  likely  to  induce  a 
paroxysm  must  be  carefully  avoided.  Restraint  by  the  strait  waist- 
coat may  be  necessary.  Plenty  of  food  must  be  given  by  the  rectum 
—  under  chloroform,  if  necessary.  The  attendants  should  be  very 
careful  that  they  do  not  inoculate  themselves  with  the  saliva  or  other 
secretions. 


o 


6  MANUAL   OF   SURGERY  chap. 


/ 


^  ! 


TETANUS 

Etiology. — Tetanus  is  much  more  common  in  the  Tropics  than 
in  temperate  climates.  It  may  occur  at  any  age,  and  is  more 
frequent  in  men  than  in  women  (4:1),  and  especially  in  the 
debilitated.  Inoculation  occurs  through  a  wound  ;  those  which  have 
been  fouled  with  soil  containing  the  bacillus  or  into  which  splinters 
of  wood,  etc.,  harbouring  it  have  entered,  are  specially  liable  to 
infection. 

The  bacillus  Maui  is  present  in  surface  soil,  especially  in 
stables.    It  is  an  obligate  anaerobe  (see  p.  91),  and  this  is  probably  the 

reason  why  it  does  not  enter  the  blood 

^  but  remains  strictly  localised  to  the  seat 

^^    ^^      ^0  of  inoculation,    where    it   develops    and 

^  Q*^  pours   its   toxines    into    the    circulation. 

\>[''^^  It  is  never  found  in  the  blood  or  lymph 

\  or  at  a  distance  from  the  wound.      The 

■*•  yP        organism  is  small  and  develops  a  spore 

**  at  one  end,  so  that  it  resembles  a  round- 

^  _  ,    .„.     ,  headed  nail  or  small  drum-stick.      These 

Fig.  29. — Tetanus  bacilli  and  spores. 

spores  are  very  resistant,  but  boiling  kills 
them  in  a  few  minutes.  Kitasato  has  isolated  tetanine,  tetano- 
toxine,  and  tetanus  tox-albumose  from  pure  cultures ;  they  are  all 
toxic,  but  the  last  is  the  most  virulent.  The  antitoxin  is  referred 
to  under  Treatment. 

Symptoms. — Tetanus  usually  supervenes  in  from  three  to  five 
days  after  inoculation,  but  may  occur  earlier  or  be  postponed  for  a 
month  or  more.  The  onset  is  usually  sudden,  but  sometimes 
more  gradual,  the  patient  complaining  of  general  malaise  and 
showing  mental  uneasiness.  Neuralgic  pain  in  the  wound  may, 
though  rarely  does,  occur.  With  the  onset  of  the  disease  the 
patient  experiences  stiffness  and  cramp  about  the  muscles  of  the 
neck,  face,  and  jaws,  with  difficulty  in  opening  the  mouth.  This  is 
quickly  followed  by  tetanic  spasm  of  the  muscles,  especially  those 
supplied  by  the  fifth,  seventh,  and  eleventh  cranial  nerves.  The 
jaw  is  tightly  clenched  (lock-jaw  or  trismus) ;  the  natural  lines 
about  the  face  and  forehead  are  deepened,  and  the  patient  has  a 
prematurely  aged  look ;  the  angles  of  the  mouth  are  retracted  into 
a  fixed  mirthless  smile  (risus  sardonicus).  The  sterno-mastoids 
and  muscles  of  respiration  are  strongly  contracted,  and  thus 
produce  difficulty  in  breathing,  which  is  short  and  catchy. 
Occasionally  the  spasm  is  confined  to  the  muscles  mentioned,  but 


VII  TETANUS  137 

more  usually  the  spinal  nerves  become  affected  and  tetanic  spasms 
are  almost  universal ;  the  legs  and  forearms  generally  escape.  The 
respiratory  difficulty  may  be  marked ;  the  voice  is  feeble  and 
more  or  less  cyanosis  is  induced.  Epigastric  pain  is  usually 
present,  and  is  probably  due  to  spasm  of  the  diaphragm.  The 
tetanus  is  constant,  but  is  temporarily  increased  by  violent  and 
extremely  painful  paroxysms  of  a  cramp-like  nature.  These  may 
be  induced  by  the  slightest  cause,  such  as  a  draught  of  cold  air,  a 
noise,  shaking  the  bed  or  merely  touching  the  skin  ;  such  paroxysms 
are  very  painful,  may  last  a  few  seconds  or  many  minutes,  and  are 
repeated  at  long  or  short  intervals. 

During  a  paroxysm  the  whole  body  is  usually  arched  backwards 
through  violent  contraction  of  the  dorsal  muscles  (opisthotonos) ; 
the  neck  is  hyper-extended,  the  occiput  being  approximated  to  the 
interscapular  region,  and  the  face  looking  vertically  upwards ;  the 
chest  is  pushed  forwards,  and  is  in  the  position  of  expiration ;  the 
abdomen  is  flat  and  hard  as  a  board,  and  the  sections  of  the  recti 
stand  prominently  out.  The  muscular  contraction  may  be  so 
violent  that  the  muscles  are  ruptured,  and  considerable  haemorrhage 
occurs  into  their  substance ;  occasionally  bones  (especially  the 
ribs)  are  broken.  The  contracted  muscles  are  dense  and  hard  to 
the  touch. 

Sleeplessness  is  a  marked  feature  of  the  disease,  but  the 
intellectual  faculties  remain  clear  and  unclouded  to  the  last.  If 
sleep  is  induced  by  treatment  the  muscles  partially  relax,  but 
contract  again  with  waking. 

Fever  may  be  absent  throughout  the  disease,  but  it  usually 
appears  in  a  few  hours  and  is  often  high ;  hyperpyrexia  is  not  un- 
common. The  fever  is  probably  dependent  upon  irritation  of  the 
heat  centres  by  the  toxines. 

Sweating  is  often  profuse,  but  may  be  absent.  Towards  the 
end  of  the  disease  the  pulse  becomes  irregular,  very  rapid,  and 
is  counted  with  difficulty. 

Diagnosis. — Lock-jaw  is  the  earliest  and  one  of  the  most 
prominent  signs  of  tetanus,  and  may,  before  other  symptoms 
have  developed,  be  confounded  with  the  temporary  closure  of  the 
jaws  produced  by  difficulty  in  cutting  a  misplaced  wisdom  tooth. 
The  presence  of  a  recent  wound,  coupled  with  the  evident  affection 
of  the  facial  and  neck  muscles,  and  in  some  cases  the  age  of  the 
patient,  are  sufficiently  diagnostic.  Hysteria  occasionally  simulates 
tetanus,  but  the  distinction  is  easy. 

Rabies  and  tetanus  can  hardly  be  mistaken  (p.  133).     Poison- 


138  MANUAL  OF  SURGERY  chap. 

ing  by  strychnia  presents  signs  very  like  tetanus,  but  the  absence 
of  a  wound,  the  suddenness  of  the  onset,  and  the  fact  that  the 
muscular  contractions  are  clonic  and  not  tonic,  and  that  there  are 
periods  of  complete  muscular  relaxation,  will  prevent  any  mistake. 

Prognosis. — The  shorter  the  incubative  period  the  more 
violent  is  the  tetanus,  and  the  more  quickly  will  a  fatal  result  ensue. 
Death  usually  occurs  in  from  three  to  seven  days,  and  should  the 
patient  survive  beyond  this  time  he  may  eventually  recover.  The 
fatal  termination  may  be  due  to  exhaustion,  spasm  of  the  glottis 
or  respiratory  muscles,  or  to  cardiac  spasm  or  paralysis ;  the  latter 
ensuing  in  consequence  of  the  greatly  increased  peripheral 
resistance  to  the  circulation  induced  by  the  powerful  tetanic 
contractions. 

Treatment. — The  wound  must  be  freely  opened  up  if  necessary 
and  thoroughly  cleaned  with  i  :  1000  mercuric  solution,  free  drain- 
age being  ensured.  If  a  foreign  body  is  suspected  it  should  be 
sought  for  and  removed. 

Amputation  is  usually  discredited  by  surgeons,  but  it  may  here 
be  noted  that  as  the  bacillus  is  strictly  confined  to  the  wound, 
amputation  must  effectually  remove  it  and  thereby  prevent  any 
fresh  absorption  of  its  toxines.  The  bowels  must  be  opened  and 
kept  acting,  and  the  action  of  the  skin  and  kidneys  promoted  by 
diaphoretics  and  diuretics.  Every  known  anti-spasmodic  has  been 
used,  but  without  any  very  marked  effect,  except  in  chronic  cases. 
Chloral,  physostigmine,  morphia,  and  chloroform  are  those  on 
which  some  reliance  can  be  placed.  The  patient  is  very  tolerant 
of  these  drugs,  and  they  must  be  given  in  large  doses  and  pushed 
until  some  distinct  physiological  effect  is  produced.  Violent  and 
agonising  paroxysms  are  best  controlled  by  the  inhalation  of 
chloroform,  and  with  the  help  of  this  drug  the  patient  may  be 
fed  and  stimulants  administered  through  a  stomach  tube  or  by 
enemata.  Baccelli  strongly  advocates  the  hypodermic  injection  of 
a  3  per  cent  solution  of  carbolic  acid,  and  states  that  it  promptly 
relieves  the  symptoms,  and  is  more  successful  than  any  other  treat- 
ment, including  that  by  antitoxin.  The  drug  must  be  freely  given 
in  doses  of  3  or  4  centigrammes  of  the  solution  repeated  several 
times  during  the  twenty-four  hours ;  its  free  use  is  especially  recom- 
mended. Out  of  thirty-four  cases  treated  by  this  method  only  one 
died. 

Antitoxin  injections. — The  tetanus  antitoxin  serum  (intro- 
duced by  Tizzoni)  is  obtained  from  horses  which  have  been  arti- 
ficially  immunised   by   injections   of   toxine   solution  of   gradually 


711 


ACTINOMYCOSIS  i39 


increasing  strength.  Three  or  four  days  after  the  last  inoculation 
the  animal  is  bled  by  means  of  a  cannula  in  the  jugular  vein  ;  the 
blood  is  allowed  to  coagulate  for  twenty-four  hours,  and  the  anti- 
toxin serum  is  then  drained  off.  This  serum  is  evaporated  to 
dryness  in  vacuo  over  sulphuric  acid,  since  heat  destroys  its  pro- 
perties. The  powder  thus  obtained  may  be  kept  like  any  other 
drug  in  sealed  tubes,  and  when  required  for  use  is  dissolved  in 
sterilised  water  without  heat ;  i  gramme  may  be  dissolved  in  5  or 
10  c.cm.  of  water. 

A  gramme  of  the  dried  serum  Is  equivalent  to  10  c.cm.  of  the 
wet.  In  the  treatment  of  tetanus  the  injections  are  made  into  the 
abdominal  wall  or  thighs,  or  both.  It  is  advisable  to  start  the 
treatment  with  20-40  c.cm.  of  the  fluid  serum  (=2-4  grammes 
dried),  to  be  followed  up  by  a  quarter  of  that  dose  every  six  hours. 
The  benefit  is  sometimes  immediate,  but  the  real  value  of  the 
drug  is  open  to  question ;  many  cases  are  certainly  not  appreciably 
relieved. 

There  seems,  from  perusal  of  the  published  cases,  no  doubt  that 
acute  cases  are  not  so  amenable  as  are  chronic,  and  it  must  not  be 
forgotten  that  50  per  cent  of  the  latter  recover  in  any  case. 

Roux  and  Borrel'  have  successfully  treated  tetanus  by  Intra- 
cerebral injection  of  the  antitoxin.  A  small  incision  is  made 
through  the  scalp  and  a  hole  made  in  the  skull  with  a  small  drill 
in  the  centre  of  a  line  drawn  from  the  outer  angle  of  the  orbit  to 
the  middle  of  a  line  from  one  auditory  meatus  to  the  other.  A  fine 
blunt  needle  is  inserted  into  the  brain  for  about  ij  to  2  inches, 
and  .5  grain  of  dry  antitoxin  in  5  cm.  of  water  is  very  slowly  in- 
jected so  that  it  may  be  absorbed.  The  operation  is  repeated  on 
the  other  side  and  antitoxin  is  also  given  hypodermically.  The 
object  of  this  method  is  to  immunise  the  nerve  centres. 

The  antitoxin  treatment  should  be  combined  with  the  ad- 
ministration of  chloral,  physostigmine,  etc. 

ACTINOMYCOSIS 

Etiology. — Actinomycosis  is  a  very  chronic  disease,  due  to  the 
aetinomyees  op  ray  fung-us,  one  of  the  Cladothricacise.  The 
fungus  occurs  in  the  form  of  small  grayish  or  sulphur-yellow 
nodules  about  the  size  of  a  hemp  seed,  each  of  which  is  a  cluster 
of  yet  smaller  masses.  The  difference  in  colour  is  a  question  of 
age,  the  yellow  masses  having  undergone  fatty  degeneration. 

Microscopically  the  fungus  is  seen  to  consist  of  a  central  felt- 


I40  MANUAL  OF   SURGERY  chap. 

work  of  branching,  wavy  filaments,  and  coccus-like  spores  ;  radiating 
from  the  central  mass  are  filaments,  which  are  often  branched  and 

clubbed  at  their  extremities ;  these 
clubbed  filaments  are  probably  the  de- 
generated ends  of  those  forming  the 
central  network. 

Bostrom  has  shown,  by  cultivation 
and  inoculation,  that  the  central  fila- 
ments, and  not  the  club-shaped  radiat- 
ing   processes,    are    the    true    infective 

Fig.  30. — Actinomycosis  hominis.         aSfCntS 

(Ziegler.)  °  "  .  .        .  ,   .     _  .   , 

Actmomycosis  is  chiefly  met  with 
attacking  the  jaws  and  tongue  of  horned  cattle,  but  is  not  directly 
communicated  by  them  to  man.  Inoculation  may  occur  through 
the  respiratory  or  alimentary  tracts,  especially  by  the  mouth  and 
pharynx.  Abrasions,  ulcers,  and  carious  teeth  probably  open  up 
paths  for  infection. 

The  fungus  is  introduced  by  barley  grains  or  straw.  In  man 
the  liver  is  a  common  seat  of  the  affection,  inoculation  being 
effected  through  the  intestinal  tract,  especially  the  colon.  The 
disease  spreads  by  continuity  of  tissue  and  by  the  lymphatic 
paths. 

Morbid  anatomy  and  signs. — The  disease  is  usually  very 
chronic,  and  is  characterised  by  the  formation  of  a  dense,  slowly 
growing  mass  composed  of  round-celled  infiltration,  which  subse- 
quently undergoes  fatty  degeneration  and  necrosis.  The  granuloma 
is  surrounded  by  more  or  less  dense  scar  tissue,  which  may  be 
calcified ;  the  slowness  of  the  growth,  and  the  tendency  to  spon- 
taneous arrest  is  directly  proportional  to  the  amount  and  density 
of  the  fibrous  tissue.  By  gradual  invasion  of  the  tissues  the 
granuloma  increases  in  size  and  affects  bones,  muscles,  and  indeed 
any  tissue  it  encounters.  The  mass  is  semi-elastic,  and  as  the 
skin  is  approached  and  thinned,  soft  fluctuating  areas  may  be 
detected.  These  break  down  and  result  in  sinuses,  which  are 
often  numerous  and  honeycomb  the  mass.  The  discharge  is  thin 
and  sanious,  or  almost  pure  pus,  and  contains  the  globe-like  bodies 
formed  by  the  fungus.  Pure  pus  and  abscess  formation  is  the 
exception,  and  is  perhaps  due  to  the  presence  of  ordinary  pyogenic 
organisms.  The  glands  are  not  affected ;  there  is  no  pain,  and 
constitutional  symptoms  only  occur  when  the  seat  of  the  disease  is 
some  part  of  vital  importance.  The  parts  first  infected  may  heal 
completely,  the  disease  spreading  in  some  other  direction;  spon- 


VII  MYCETOMA— MADURA   FOOT  141 

taneous  cure  has  been  observed.  Acute  cases  are  sometimes  met 
with.  The  symptoms  naturally  depend  upon  the  seat  of  the  mis- 
chief; if  the  jaws  be  attacked,  the  process  may  extend  to  the  neck, 
backwards  to  the  pharynx  and  spine,  or  upwards  to  the  skull. 
If  the  liver  or  internal  organs  suffer,  characteristic  symptojns,  due 
to  the  lesion  and  interference  with  the  functions  of  the  organ,  will 
appear. 

Diagnosis. — From  sarcoma  the  disease  may  be  diagnosed  by 
its  very  slow^  growth,  painless  course,  the  absence  of  secondary 
deposits  in  the  glands,  and  by  the  presence  of  the  fungus  in  the 
discharge  and  granulation  mass. 

When  the  liver  or  other  internal  organ  is  affected  the  diagnosis 
may  be  extremely  difficult,  as  it  may  be  impossible  to  secure  the 
fungus. 

Prognosis. — If  the  disease  is,  from  its  situation,  not  amenable 
to  surgical  treatment,  it  will  prove  fatal,  but  may  persist  for  many 
months.  Septic  infection  or  some  intercurrent  mischief  usually 
terminates  the  case. 

Treatment. — Complete  eradication  of  the  granulomatous  mass 
by  excision  or  sharp-spooning,  or  both  combined,  is  the  only  avail- 
able treatment.  Iodide  of  potassium  internally  is  said  to  be 
useful. 


MYCETOMA MADURA    FOOT 

Etiology. — Mycetoma  is  due  to  a  fungus  closely  allied  to,  and 
thought  by  Kanthack  to  be  identical  with,  the  actinomyces.  Boyce 
and  Surveyor  regard  it  as  distinct,  and  have  cultivated  from  it  a 
form  of  streptothrix ;  but  as  yet  this  has  not  been  inoculated. 
Clinically  there  are  many  points  of  resemblance  and  contrast 
betw^een  actinomycosis  and  mycetoma.  The  latter  is  common 
among  the  natives  of  India  w^ho  work  in  the  fields  bare-footed ; 
inoculation  takes  place  through  a  wound.  The  disease  may 
attack  the  hands. 

Signs. — Mycetoma  is  very  chronic.  It  begins  usually  by  the 
formation  of  one  or  more  flat,  raised,  indurated  tubercles  or  papules, 
which  subsequently  soften  and  break  down,  leaving  an  unhealthy 
sinus.  Masses  of  granulation  tissue  develop  in  the  connective 
tissue,  and  the  bones,  muscles,  etc.  are  gradually  invaded,  the  foot 
being  much  enlarged.  The  sinuses  riddle  the  tissues  and  may 
freely  intercommunicate.  Abscesses  may  result.  In  the  sinuses 
and  granulomatous  tissue,  black  deposits  like  coarse   gunpowder. 


142  MANUAL  OF  SURGERY  chap,  vii 

or  pale  masses  resembling  fish-roe  are  seen  ;  these  are  the  mycetoma 
colonies.  Destruction  is  progressive  and  the  disease  may  last  for 
years ;  it  is  unaccompanied  by  pain  or  constitutional  symptoms. 
Deposits  in  internal  organs  do  not  occur. 

Treatment. — The   treatment  is  the  same  as  that  of  actino- 
mycosis.    In  advanced  cases  amputation  should  be  performed. 


CHAPTER    VIII 
Surgical  Infective  Diseases  {Continued) 

TUBERCLE 

Tubercle  is  an  infective  inflammatory  disease  clinically  char- 
acterised by  its  chronic,  insidious  course,  by  caseation  and  softening 
of  the  inflammatory  products,  and  by  its  gradual  invasion  and 
destruction  of  the  tissues  unaccompanied  by  any  attempt  at 
organisation  or  perfect  repair.  Tubercle  is,  in  almost  all  cases,  a 
local  disease,  capable  of  eradication  in  situations  permitting  radical 
surgical  treatment ;  but  in  some  instances  invasion  of  the  body 
generally  may  occur  and  acute  tuberculosis  ensues.  In  rare  cases, 
acute  general  tuberculosis  may  occur  independently  of  any  local 
tubercle.  As  compared  with  the  extreme  frequency  of  local 
tubercle,  the  general  disease  is  very  rare. 

It  is  now  generally  admitted  by  pathologists  that  those  condi- 
tions formerly  called  scrofulous  or  strumous  are  in  reality  tuber- 
cular. By  the  term  scrofula  is  now  meant  a  certain  constitutional 
tendency  to  the  development  of  low  and  intractable  forms  of 
chronic  inflammation  of  a  tubercular  nature,  as  the  result  of  the 
most  trivial  local  causes.  Scrofula  is  a  term  better  abandoned,  but 
long  usage  will  probably  ensure  its  survival  for  many  years. 

Scrofula  or  struma  must  not  be  regarded  as  a  disease  in  the 
ordinary  sense  of  the  term,  although  it  is  true  that  the  diminished 
vital  resistance  of  the  tissues,  which  is  the  leading  characteristic  of 
the  condition,  is  a  departure  from  the  normal  standard  of  health. 
Scrofula  is,  in  fact,  a  condition  predisposing  to  tubercular  infection, 
but  is  not  the  disease  itself.  This  predisposition  doubtless  lays 
the  patient  open  to  diseases  of  all  kinds,  and  unfits  him  to  battle 
against  them ;  but  the  great  majority,  if  not  all,  of  the  local  lesions, 


144  MANUAL  OF  SURGERY  chap. 

formerly  described  as  scrofulous,  are  now  known  to  be  tubercular, 
although  diligent  search  is  often  necessary  for  discovery,  in  the 
diseased  tissues,  of  the  viateries  7iwrbi  characteristic  of  tubercle. 

Inoculation  of  susceptible  animals  with  the  inflammatory  pro- 
ducts from  a  so-called  scrofulous  or  strumous  lesion  produces  in 
them  typical  tuberculosis. 

Etiology. — The  scrofulous  or  tubercular  tendency  is  usually 
inherited  from  the  parents,  but  under  certain  conditions  may  be 
acquired.  Hereditary  transmission  is  not  equally  marked  in  all 
members  of  the  same  family,  some  of  whom  may  entirely  escape. 

The  parents  are  usually  themselves  tubercular,  and  if  both 
suffer,  transmission  is  more  certain  and  severe ;  should  one  only 
be  tubercular,  it  is  worse  if  that  one  be  the  mother.  Independ- 
ently of  the  tubercular  diathesis  in  the  parents,  any  serious  con- 
dition of  ill -health,  especially  syphilis,  may  render  the  offspring 
tubercular. 

The  tubercular  tendency  may  be  aggravated  or  diminished 
according  to  whether  the  child,  during  its  early  years,  be  placed 
under  conditions  favourable  to  health  or  the  reverse.  Children 
living  under  bad  hygienic  conditions,  especially  in  damp,  over- 
crowded, and  ill-ventilated  dwellings,  with  their  usual  accompani- 
ments of  dirt  and  bad  feeding,  are  specially  prone  to  have  their 
inborn  tubercular  tendency  aggravated,  or,  should  they  have  been 
born  healthy,  to  acquire  it.  Dyspepsia  is  an  important  predispos- 
ing cause. 

Tubercular  children  often  betray  the  diathesis  by  their  physical 
and  mental  attributes.  There  are  two  chief  types — the  sanguine 
and  the  phlegmatic. 

The  sanguine  type  is  always  hereditar)',  and  is  marked  by  mental 
acuteness,  precocity,  and  vivacity.  The  child  is  usually  tall, 
slender,  and  gracefully  built,  but  the  chest,  especially  in  its  antero- 
posterior measurement,  is  small.  The  features  are  delicately  cut, 
the  complexion  good,  and  the  child  often  very  attractive. 

The  skin  is  delicate,  clear,  and  fine,  so  that  the  subcutaneous 
veins  are  plainly  seen.  The  hair  is  fair,  fine,  and  silky ;  long 
downy  hairs  are  often  abundant  over  the  back,  shoulders,  and  fore- 
arms. The  eye-lashes  are  long,  abundant,  and  gracefully  curved ; 
the  eyes  large,  bright,  and  intelligent-looking,  and  often  blue  in 
colour. 

The  phlegjfiatic  type  may  be  hereditary,  but  is  often  acquired, 
and  is  seen  especially  among  the  poor  of  large  cities.  It  is  cjpsely 
allied  to  the  rickety  physiognomy.     The  child  is  ill-grown,  stunted, 


VIII  SURGICAL  INFECTIVE   DISEASES  145 

awkward,  and  ungainly.  The  mental  condition  is  dull.  The 
features  are  coarse,  large,  thick,  and  ugly.  The  skin  is  coarse  and 
greasy,  pale  and  pasty  in  appearance  owing  to  the  abundance  of 
lymphatic  tissue.  The  hair  is  coarse,  and  of  a  reddish,  sandy,  or 
dark  brown  tint.  The  finger  ends  may  be  clubbed  and  the  nails 
curved. 

It  must  not  be  supposed  that  all  tubercular  children  will  fall 
under  one  or  other  of  these  types,  for  there  are  many  gradations 
between  them.  A  mixture  of  the  two  is  sometimes  spoken  of  as 
"pretty  struma." 

While  the  strumous  diathesis  is  a  strong  predisposing  cause  of 
tubercle,  its  presence  is  by  no  means  necessary  for  infection. 
Generally  speaking,  man  is  not  susceptible  to  tubercle ;  for  it  niust 
be  remembered  that  probably  all  of  us  run  daily  risk  of  infec- 
tion. Tubercular  affections  occur  especially  in  early  life,  and  are 
comparatively  rare  after  the  age  of  twenty.  Sometimes  the 
disease  manifests  itself  in  later  life,  especially  in  women  (senile 
tubercle). 

The  tuhe7'cle  hacillus  was  discovered  by  Koch  in  1882,  and  is  a 
short,  thin,  slightly  curved,  non-motile  organism,  multiplying  in  the 
body  by  fission  and  spores.     It  is 
an  aerobic  obligate  parasite  (see 
p.  91),  although  capable  of  /ivuig 
outside  the  host.     The  organisms 
are  sometimes  very  few  in  number, 
and  difficult  of  detection.     They 
are    readily    stained    by    Gram's 
method    or    by    Ziehl's    fuchsine 
stain  ;  they  are  present  in  the  pus 
and    discharges    from    tubercular 
lesions,  in  the  tissues,  and  especi-         ^^^  sx.-TuWiebaciiUin  sputum, 
ally  in  the  epithelioid  and  giant 

cells  to  be  presently  described.  The  organisms  are  readily  killed 
by  boiling,  by  carbolic  acid,  or  by  mercury  solution,  but  the  spores 
are  more  resistant  than  are  the  mature  bacilli. 

Modes  of  infection. — The  bacilli  usually  gain  entrance  through 
the  mucous  membrane  of  the  throat  or  respirator)'  tract  and  show  a 
marked  preference  for  lymphatic  structures.  In  many  cases  the 
entry  of  the  bacillus  is  favoured  by  some  antecedent  inflammation 
or  slight  injury.  The  organism  taken  Nsi-a  the  food  is  usually 
destroyed  in  the  stomach,  so  that  primary  inoculation  of  the 
intestinal  mucous  membrane  does  not  occur;  but  in  cases  of 
VOL.  I  L 


146  MANUAL  OF   SURGERY  chap. 

phthisis,   the  large  quantity  of  bacilli  swallowed  with  the  sputum 
may  excite  intestinal  tuberculosis. 

Tuberculous  meat,  unless  thoroughly  cooked,  and  the  milk  of 
cows  with  tubercular  udders,  may  convey  infection ;  such  modes, 
however,  ought  never  to  occur  if  due  care  be  taken  by  butchers  and 
cowkeepers. 

Very  rarely  a  wound  may  be  the  seat  of  inoculation  (see 
Anatomical  Wart,  p.  153). 

Development  and  spread  in  the  tissues. — The  bacilli  are 
taken  up  by  the  leucocytes,  and  multiplying  in  the  tissues,  lead  to  the 
formation  of  tubercle  nodules.  The  disease  may  spread  by  local 
invasion  of  the  tissues,  or  by  the  lymphatics  to  the  nearest  glands. 
In  other  cases  dissemination  through  the  blood- stream  occurs. 
Each  focus  of  tubercular  mischief  may  be  the  source  of  further  in- 
fection, the  bacilli  being  taken  up  by  leucocytes  and  carried  by  the 
lymph-  or  blood -stream  to  parts  where  they  can  develop.  No 
doubt  multiple  tubercular  lesions  are  due  to  embolic  infection  ;  and 
the  occurrence  of  general  tuberculosis  is  dependent  partly  on  the 
dose  of  the  poison,  and  partly  on  the  marked  predisposition  of  the 
tissues. 

Morbid  anatomy. — Naked-eye  appearances. — Tubercular 
inflammation  is  characterised  anatomically  by  the  formation  at  the 
seat  of  inoculation  of  small  nodules  or  miliary  tubercles.  These 
present  somewhat  different  appearances  according  to  their  age. 
When  first  recognisable  by  the  naked  eye,  the  nodule,  which  is 
about  the  size  of  a  pin's  head  or  larger,  projects  somewhat  from  the 
surface,  and  is  surrounded  by  a  hyperaemic  zone.  It  is  dense  in 
consistency,  semi-translucent,  and  grayish  in  colour. 

After  a  time,  when  caseation  occurs,  the  consistency  is  lost  and 
the  nodule  assumes  a  yellow  colour  and  cheesy  appearance  (yellow 
or  crude  tubercle).  By  the  coalescence  of  adjacent  nodules  a 
larger  mass  is  formed  (conglomerate  tubercle),  and  if  the  disease 
be  still  active  this  goes  on  increasing  in  size.  Round  such  a  mass  the 
tissues  are  studded  with  tubercles,  each  surrounded  by  a  hyperaemic 
zone,  and  thus  gradual  invasion  of  the  tissues  takes  place.  The 
tubercular  nodule  is  non-vascular — a  fact  of  considerable  importance 
in  regard  to  its  subsequent  fate. 

Mieroseopie  anatomy. — When  examined  microscopically,  a 
miliary  tubercle  as  above  described  is  seen  to  consist  of  numerous 
smaller  nodules,  each  of  which  is  constructed  as  follows.  In  the 
centre  is  a  multi-nucleated  giant  cell  with  branched  processes ; 
these  are  continuous  with  a  fine  fibrillar  reticulum  which  pervades 


VIII 


SURGICAL  INFECTIVE   DISEASES 


147 


the  microscopic  tubercle,  but  which  is  not  readily  demonstrable 
(Fig.  T,^,  p.  148).  The  existence  of  this  reticulum  is  denied 
by  some  authorities.  The  nuclei  are  usually  arranged  at  one 
pole  of  the  giant  cell,  the  bacilli  at  the  other,  as  if  there  were 
negative  chemiotaxis  between  them ;  in  other  cases  the  nuclei 
may  lie  round  the  margin,  the  bacilli  then  being  centrally  dis- 
posed. Sometimes  two  or  three  giant  cells  are  present,  one 
usually  being  more  developed  than  the  others.  The  origin  of  the 
giant  cells  is  accounted  for  in  different  ways  by  different  observers, 
and   perhaps    they    do    not    always    arise    in    the    same    manner. 


Fig.  32. — Miliary  tuberculosis  of  the  liver  (Ziegler).     a,  mature  tubercle  ; 
d,  cluster  of  small  cells  forming  an  incipient  tubercle. 

According  to  Koch  and  Metchnikoff,  they  are  aggregations  of 
leucocytes  (phagocytes) ;  Baumgarten  denies  this  and  attributes 
them  to  the  connective  tissue  or  endothelial  cells,  which,  he  asserts, 
are  large,  because  they  have  undergone  incomplete  division — 
the  nuclei  dividing,  but  the  protoplasm  merely  increasing.  Others 
consider  that  the  giant  cells  are  merely  lymph  coagula,  the  nuclei 
being  cells  caught  up  in  the  coagulum ;  but  this  would  seem  to  be 
negatived  by  the  peculiar  and  constant  arrangement  of  the  nuclei 
and  bacilli. 

The  giant  cell  is  surrounded  by  a  zone  of  large  mono-nuclear, 
epithelioid  cells  with  granular  protoplasm ;  these  are  derived  from 
the  endothelial  and  connective  tissue  cells.  In  and  between  these 
cells  bacilli  are  present.     Outside  this  is  a  zone  of   small  round 


148 


MANUAL  OF  SURGERY 


CHAP. 


cells  (migrated  leucocytes)  gradually  becoming  less  numerous  as  the 
healthy  tissue  is  reached  (Fig.  33). 

Such  is  the  anatomy  of  a  typical  nodule  ;  but  in  some  cas^es, 
especially  if  the  formation  has  been  rapid,  the  type  is  departed 
from  and  the  giant  cell  may  be  absent. 

The  pecuHar  association  and  grouping  of  these  cellular  elements 
is  characteristic  of  tubercle,  but  the  individual  cells  themselves  are 
not ,  thus  giant  cells  are  met  with  in  developing  granulation  tissue, 


-c^ 


Fig.  33. — Tubercular  nodule  from  a  case  of  white  swelling  of  the  knee-joint. 
a,  giant  cell  ;  ^,  epithelioid  cells  ;  c,  lymphoid  cells.     (Ziegler.) 

carious  bone,  and  myeloid  tumours,  and  the  epithelioid  and  small 
round  cells  are  commonly  present  in  simple  inflammations. 

The  distinctive  characters  of  the  tubercular  giant  cell  lie  in  the 
arrangement  of  its  nuclei  and  the  presence  of  the  bacilli. 

Ultimate  fate  of  the  tubercular  tissue. — Caseation  is  a  con- 
stant occurrence  in  tubercular  nodules.  The  change  is  due  in  part 
to  the  absence  of  vessels,  in  part  to  the  irritating  effect  of  the 
toxines  produced  by  the  bacilli.  Caseation  occurs  first  in  the 
centre  of  the  tubercle  —  that  is,  in  the  part  most  remote  from 
the  surrounding  vessels  and  most  favoured  by  the  organism  and  its 
spores.  The  process  is  usually  slow,  but  may  be  rapid.  The 
giant  cell  becomes  granular  and  loses  its  characteristic  appearance, 
the    nuclei    and    bacilH    being    no    longer    distinguishable;    the 


VIII  SURGICAL  INFECTIVE   DISEASES  149 

epithelioid  and  round-ccllcd  zones  follow  suit,  and  the  whole  is  con- 
verted into  a  cheesy  mass. 

The  caseous  material  possesses  infective  properties,  and  may 
excite  suppuration  in  the  neighbouring  tissues ;  the  pus,  mixed 
with  the  softened  caseous  material,  forms  a  tubercular  abscess. 
Sometimes  no  pus  is  formed,  but  the  caseous  mass  softens  and  is 
mixed  with  fluid  derived  from  the  surrounding  tissues.  A  chronic 
tubercular  abscess  is  surrounded  and  limited  by  a  more  or  less 
dense  capsule  of  new  connective  tissue ;  the  wall  is  the  seat  of 
tubercular  nodules  with  bacilli,  by  the  successive  breaking  down  of 
which  the  abscess  continues  to  increase  in  size.  The  contents 
of  such  an  abscess  are  not  pure  pus,  but  consist  of  sero-purulent 
fluid,  floating  in  which  are  shreds  and  masses  of  curdy,  caseous 
material. 

Caseation  does  not,  however,  necessarily  entail  softening  and 
abscess  formation.  The  fluid  may  be  absorbed  and  the  caseous 
patch  dry  up  and  become  encapsuled  by  new  connective  tissue. 
Such  a  mass  is  practically  a  foreign  body,  and  is  incapable  of  under- 
going any  further  active  change  ;  but  sometimes,  even  after  many 
years,  some  trivial  cause  may  reawaken  the  mischief,  and  thus  an 
abscess  forms  (residual  abscess).  Caseous  masses  may  become 
partially,  but  are  rarely  wholly,  absorbed. 

The  amount  of  new  scar  tissue  may  be  considerable,  and  may 
enclose  a  small  caseous  patch  so  that  the  bacilli  are  completely 
isolated  and  spontaneous  cure  results.  A  caseous  mass  may  be- 
come calcified.  According  to  Metchnikoff,  the  process  of  calcifica- 
tion is  directly  dependent  upon  the  activity  of  the  giant  cells ;  he 
says,  "  The  bacillus  defends  itself  by  the  secretion  of  cuticular 
membranes,  and  probably  also  by  the  production  of  toxines,  while 
the  giant  cell  secretes  a  calcareous  deposit,  by  means  of  which  it 
walls  in  the  bacillus  and  usually  succeeds  in  killing  it.  The  giant 
cell  also  probably  produces  digestive  fluids  which  aid  it  in  attacking 
and  digesting  the  bacillus," 

If  repair  occurs  after  abscess  or  ulceration  due  to  tubercle,  it  is 
always  more  or  less  imperfect.  The  scar  is  thin  and  may  break  down 
again,  especially  if  it  is  irritated.  On  account  of  the  feebleness  of 
the  scar  tissue,  cicatrisation  and  contraction  are  but  little  marked. 

DiagTlOsis. — The  diagnosis  of  tubercle  is  usually  easy  and  is 
rendered  certain  by  the  discovery  of  the  bacillus.  The  general 
state  of  the  patient,  his  age,  the  history  of  the  case,  the  chronic 
nature  of  the  mischief  and  its  destructive  tendencies,  and  finally,  the 
seat  of  the  disease  are  the  main  diagnostic  features.     The  lesions 


I50  MANUAL   OF   SURGERY  chap. 

of  the  late  stage  of  hereditar)'  syphilis  sometimes  very  closely 
resemble  those  of  tubercle  (see  p.  206).  In  doubtful  cases,  e.g. 
renal  tuberculosis,  experimental  inoculation  of  a  susceptible  but 
healthy  animal,  e.g.  a  guinea-pig,  is  a  valuable  means  of  diagnosis. 

Prognosis. — The  prognosis  depends  upon  whether  the  seat 
and  extent  of  the  mischief  admit  of  radical  surgical  treatment. 

Generally  speaking,  it  may  be  said  that  localised  tubercle  which 
can  be  entirely  removed  can  be  cured.  If  the  disease  be  not 
amenable  to  such  treatment,  it  usually  runs  a  progressive  course 
and  terminates  fatally.  Spontaneous  cure  occasionally  occurs  when 
the  disease  is  limited  and  the  patient  not  very  susceptible. 

Principles  of  treatment  in  surgical  tuberculosis. — 
General  treatment. — Every  endeavour  must  be  made  to  main- 
tain and  improve  the  general  health  of  those  suffering  from  tuber- 
cular lesions.  Warm  clothing,  good  hygienic  surroundings,  with 
suitable  and  abundant  food,  are  essential.  The  digestive  and 
excretory  functions  must  receive  special  attention,  for  unless  these 
are  acting  properly,  healthy  nutrition  is  impossible.  Fresh  country 
air,  preferably  at  the  seaside,  and  in  a  dry  and  equable  atmosphere, 
is  most  important ;  and  the  patient  should  enjoy  as  much  exercise 
in  the  open  as  possible.  It  is  now  fully  recognised  that  fresh  air 
is  one  of  the  most  important  means  of  combating  tubercular  dis- 
ease. Residence  at  some  bracing  seaside  resort  such  as  i^Iargate, 
or  in  the  higher  Alpine  regions  of  Davos  or  St.  Moritz,  and  other 
well-known  health  resorts,  is  advisable  in  bad  cases,  but  is  un- 
fortunately within  reach  of  the  few  only.  A  sea -voyage  to  the 
Cape  or  Australia  may  be  taken  with  advantage  when  the  tubercular 
tendency  is  well  marked,  and  after  any  local  lesion  has  been  cured 
or  benefited  by  treatment.  During  winter  months  residence  in 
Egypt  is  advisable.  The  open-air  treatment  of  tuberculosis  has 
been  attended  wi:h  marked  benefit,  about  two-thirds  of  the  patients 
showing  great  improvement.  On  the  Continent  this  method  has 
been  largely  introduced,  and  Sanatoria  are  numerous ;  the  best 
known  are  those  of  Nordach  in  the  Black  Forest,  Davos,  and 
Falkenstein  in  the  Taunus.  All  the  rooms  face  south,  and  are 
protected  from  the  prevailing  wind ;  the  patients  spend  from  9  a.m. 
to  10  P.M.  in  the  open  air,  and  sleep  with  the  windows  open.  The 
diet  is  liberal,  rest  is  enforced,  and  cold  douching  with  massage,  or 
the  latter  alone  (according  to  the  strength  of  the  patient),  are  useful 
adjuncts  to  the  treatment. 

Tonics  should  be  given  in  accordance  with  the  requirements  of 
the  case :   cod-liver  oil,  maltine.  Fellow's  syrup,  and  the  phosphate 


VIII  SURGICAL  INFECTIVE   DISEASES  151 

or  iodide  of  iron  are  those  usually  employed ;  if  there  is  marked 
anaemia,  quinine,  strychnia,  and  the  astringent  preparations  of  iron 
with  vegetable  bitters  are  indicated.  The  internal  administration 
of  guaiacol  seems  to  have  a  powerful  influence  in  arresting  the 
progress  of  tuberculosis. 

Local  treatment. — Before  softening  has  occurred,  much  may 
be  done  to  favour  the  arrest  of  the  tubercular  mischief,  unless  the 
patient's  susceptibility  is  very  marked.  In  all  cases  the  general 
principles  of  treatment  are  the  same,  but  the  details  of  their  appli- 
cation necessarily  vary  with  the  seat  of  the  disease.  Rest  of  the 
diseased  part  and  its  surroundings  is  of  primary  importance ;  it 
should  be  complete  and  long-continued.  Counter-irritation  is 
sometimes  productive  of  good  results,  and  probably  acts  by  draw- 
ing an  increased  quantity  of  blood  to  the  part,  hence  bringing 
more  phagocytes  to  deal  with  the  7nateries  morbi.  Blistering  and 
the  application  of  the  actual  cautery  may  be  useful  in  tubercular 
disease  of  bones  and  joints.  The  application  of  iodine  to  the  skin 
over  tubercular  glands  and  abscesses  is  useless  and  frequently 
mischievous ;  it  is  the  refuge  of  the  destitute. 

Any  source  of  local  irritation  must  be  removed,  especially  in 
the  case  of  the  enlarged  glands  so  often  seen  in  tubercular 
children ;  in  such  cases  removal  of  irritation  about  the  scalp, 
throat,  or  mouth  is  often  followed  by  marked  improvement,  with 
almost  complete  subsidence  of  the  glandular  swelling. 

When  caseation  and  softening  have  occurred,  the  only  treat- 
ment of  any  avail  lies  in  the  complete  eradication  of  the  whole 
area  of  the  disease  by  surgical  operation,  and  the  sooner  this  is 
done  the  better ;  for  not  only  does  delay  allow  of  local  extension, 
but  each  tubercular  focus  is  capable  of  producing  others,  or  of 
inducing  general  tuberculosis.  If  possible,  the  diseased  mass 
should  be  dissected  out  like  a  tumour,  but  when  circumstances 
will  not  permit  of  this,  it  must  be  eradicated  by  the  sharp-spoon 
and  scissors  and  the  wound  thoroughly  dusted  with  iodoform, 
which  seems  to  have  some  specific  influence  in  tubercle. 

The  special  treatment  of  tubercular  disease  of  various  organs 
and  tissues  will  be  referred  to  in  their  proper  sections. 

Tuberculin. — In  1890  Koch  prepared  a  glycerine  extract  of 
pure  cultures  of  the  bacillus  tuberculosis  known  as  tuberculin. 
By  experiment  it  was  found  that  this  substance,  when  injected 
beneath  the  skin,  had  a  wonderful  effect  on  tubercular  lesions, 
and  hopes  were  entertained  that  it  would  prove  to  be  a  powerful 
and  effective  antitoxin.     These  hopes  were  not,  however,  fulfilled, 


152  MANUAL  OF  SURGERY  chap. 

and  the  drug  proved  to  be  dangerous,  as  it  not  infrequently  wakened 
quiescent  tubercle  into  fresh  activity. 

Early  in  1897  Koch  published  {Dent.  Med.  TVoc/i.)  an  account 
of  a  new  antitoxin  which  he  calls  tuberculin  R.  This  prepara- 
tion is  yet  on  its  trial.  In  cases  of  lupus  vulgaris  the  injections 
produce  rapid  and  surprising  improvement,  but  this  appears  to 
come  to  a  standstill  after  a  time,  and  cure  cannot  be  said  to  result. 
The  drug  has  also  been  used  with  benefit  in  other  tubercular 
affections.  It  must  be  used  most  carefully  and  with  full  aseptic 
precautions ;  it  often  contains  septic  micro-organisms.  The  dose 
is  gradually  increased  from  one  to  twenty  milligrammes,  and  an 
injection  is  made  every  second  day. 

THE    SPECIAL    SEATS    OF    TUBERCLE 

No  organ  or  tissue  of  the  body  is  exempt  from  tubercular 
disease,  but  some  are  especially  prone.  In  surgical  practice  the 
glands  of  the  neck,  the  bones,  joints,  genito-urinary  tract,  peri- 
toneum, skin,  and  subcutaneous  tissue  and  mucous  membranes  are 
the  usual  seats  of  the  disease.  Of  the  viscera,  the  lungs  are  the 
common  seat,  but  tubercle  of- the  intestines,  spleen,  liver,  brain,  pia 
mater,  and  serous  membranes  is  common.  The  disease,  as  it 
attacks  the  various  parts,  will  be  fully  described  in  the  chapters 
relating  to  them,  but  tubercle  of  the  skin  and  subcutaneous  tissue 
will  be  shortly  described  here. 

Subcutaneous  tubercular  abscess  unconnected  with  disease 
of  a  bone,  joint,  or  glands  results  from  a  deposit  of  tubercle  in  the 
subcutaneous  tissue.  The  abscess  is  very  chronic  and  not  accom- 
panied by  the  usual  signs  of  inflammation.  It  is  localised  and 
elastic,  but  when  softening  occurs,  fluctuation  becomes  more  or  less 
evident.  The  overlying  skin  is  gradually  undermined  and  thinned, 
becomes  red  and  slightly  tender,  and  when  it  gives  way  the  con- 
tents are  evacuated  and  an  unhealthy  suppurating  wound  is  left. 
This  may  continue  to  discharge  and  perhaps  burrow  in  various 
directions  through  extension  of  the  tubercular  process,  and  by  the 
complete  destruction  of  the  skin  an  unhealthy  ulcer  may  result. 
Such  abscesses  require  the  treatment  given  at  p.  49. 

Tubercular  ulcers  may  be  met  with  on  the  skin  or  mucous 
membranes.  Ulcers  in  the  latter  situation  are  met  with  {^.z'.)  in 
the  tongue,  intestine,  nose,  larynx,  anus,  etc.  The  skin  ulcers  are 
chronic  and  not  amenable  to  ordinary  treatment,  but  quickly  heal 
if  thoroughly  sharp-spooned.     The  base  is  dirty  and  may  be  studded 


VIII  THE   SPECIAL  SEATS   OF  TUBERCLE  153 

wilh  granulations ;  the  edges  are  ragged,  irregular,  undermined, 
and  often  livid.  The  base  and  edges  may  be  indurated  from 
the  presence  of  tuberculous  material,  to  the  breaking  down  of 
which  increase  in  size  of  the  ulcer  is  due.  Treatment  consists  in 
free  removal  of  the  diseased  structures  by  the  sharp-spoon  and  the 
application  to  the  raw  surface  of  chloride  of  zinc  paste  or  iodoform, 
followed  by  some  simple  unirritating  dressing,  such  as  boracic 
ointment.  The  resulting  scars  are  often  depressed.  Small  ulcers 
should  be  completely  excised  ;  the  edges  of  the  skin  are  then  united, 
or  the  gap,  if  too  large  for  this,  is  covered  by  grafts  according  to 
Thiersch's  method. 

Anatomical  or  butcher's  wart. — Those  engaged  in  post- 
morfem  examinations  or  in  slaughter-houses  occasionally  develop 
on  the  hands,  especially  over  the  knuckles,  a  persistent  warty  con- 
dition which  shows  little  or  no  tendency  to  ulcerate,  although  it  is 
very  resistant  to  treatment.  The  absence  of  ulceration  is  in  marked 
contrast  to  what  occurs  in  lupus,  although  these  conditions  are 
certainly  allied.  The  tubercle  bacillus  can  often  be  found  in 
anatomical  wart,  but  it  is  by  no  means  certain  that  all  cases  are 
tubercular. 

Treatment  consists  in  the  application  of  nitric  acid  or  some 
strong  caustic,  and  if  this  fails,  the  warty  patches  must  be  freely 
sharp-spooned. 

Lupus. — Lupus  vulgaris  is  a  disease  of  the  skin  and  mucous 
membranes  due  to  the  presence  of  the  B.  tuberculosis.  Fully 
formed  tubercular  nodules  are  rarely  met  with,  the  morbid  material 
consisting  chiefly  of  round  cells ;  the  bacilli  are  demonstrated  with 
difficulty.  Lupus  is  usually  met  with  in  girls  about  the  age  of 
puberty,  and  sometimes  in  much  younger  patients;  it  may  also 
occur  about  the  hands  of  elderly  people. 

The  favourite  seat  of  the  disease  is  the  nose  and  adjacent  parts 
of  the  face.  It  begins  in  the  form  of  raised  reddish  or  brownish 
papules,  which  contain  a  material  not  unlike  apple  jelly;  these 
sooner  or  later  break  down  and  lead  to  ulceration.  The  adjacent 
patches  and  ulcers  coalesce  and  produce  considerable  tracts  of 
disease  round  which  isolated  nodules  of  varying  size  are  readily 
distinguishable.  The  broken-down  patches  are  covered  with  a 
loosely  adherent  unhealthy  scab,  beneath  w^hich  pus  is  imprisoned. 
As  the  disease  advances,  the  mucous  membrane  of  the  nose  may 
become  affected ;  the  alse  nasi  may  be  destroyed  and  the  cartilages 
and  bones  necrose,  and  hence  the  most  unsightly  deformity  results. 
Sometimes  the  disease  spreads  to  the  mucous  membrane  of  the 


154  MANUAL   OF   SURGERY  chap. 

lips,  mouth,  and  palate,  and  patches  of  it  may  be  present  in  various 
parts  of  the  body.  The  glands  of  the  neck  are  not  infrequently 
enlarged,  and  the  patient  is  pale,  anaemic,  ill-developed,  and  un- 
healthy. 

Treatment. — The  ideal  treatment  is  excision  of  the  affected 
portion  of  skin,  followed  by  grafting  the  raw  surface  by  Thiersch's 
method.  Healing  is  rapid,  and  the  resulting  scar  is  sound  and 
good.  In  many  cases,  however,  the  disease  has  extended  so  widely 
that  this  plan  is  impracticable,  and  under  such  circumstances  it 
must  be  eradicated  by  sharp -spooning.  The  patient  is  anaes- 
thetised and  every  particle  of  diseased  and  softened  tissue  is  scraped 
away;  the  raw  surface  is  then  treated  with  chloride  of  zinc  paste 
well  rubbed  in  by  means  of  a  small  piece  of  wood  or  a  glass  rod. 
The  surface  is  best  dressed  with  a  little  iodo-vaseline  spread  on 
thin  butter-cloth.  The  case  must  be  kept  under  supervision,  and 
at  the  first  sign  of  a  recurrence  of  the  disease  the  sharp-spoon  must 
be  at  once  resorted  to.  The  employment  of  tuberculin  R.  is  re- 
ferred to  at  p.  152. 

The  general  treatment  is  that  applicable  to  tubercle. 

LUPUS    ERYTHEMATOSUS 

Although  this  is  not  a  tubercular  affection  it  is  convenient  to 
describe  it  here. 

The  disease  usually  occurs  in  women  during  adult  life. 

Seat  and  morbid  anatomy.  —  Lupus  erythematosus  may 
affect  any  part  of  the  body,  but  shows  a  special  predilection  for  the 
neighbourhood  of  the  nose  and  cheeks.  The  disease  is  characterised 
by  enlargement  of  the  small  veins,  by  congestion  and  round-celled 
infiltration  of  the  cutis,  with  considerable  increase  in  the  sebaceous 
secretion.  Hyperaemic  plaques  appear  on  the  surface,  and  after  a 
time  become  covered  by  scabs  formed  of  desquamated  epithelium 
and  sebaceous  matter.  By  coalescence  of  the  plaques  a  large  area 
of  disease  results  which  spreads  over  the  cheeks  in  a  remarkably 
symmetrical  manner,  the  affected  area  taking  much  the  shape  of  a 
butterfly's  wings.  In  the  course  of  time  the  invasion  of  the  round 
cells  leads  to  atrophy  of  the  normal  tissues,  and  a  thin  white  scar 
remains.  The  disease  is  very  liable  to  relapse,  and  may  persist  for 
a  very  long  time.  There  are  practically  no  subjective  sensations 
beyond  a  little  itching,  and  the  general  health  remains  good. 
Ulceration  does  not  occur. 

Treatment. — Linear  scarification  is  one  of  the  best  forms  of 


VIII  LUPUS   ERYTHEMATOSUS  155 

local  treatment,  it  obliterates  the  vessels  and  promotes  absorption 
of  the  round-celled  infiltrate ;  the  cuts  should  be  about  an  eighth 
of  an  inch  apart  over  the  whole  area,  and  may  be  crossed  by  others 
at  right  angles  to  them.  The  application  of  mercurial  ointment,  or 
of  a  2  per  cent  solution  of  resorcin,  10  per  cent  pyrogallic  acid 
ointment,  or  tincture  of  iodine  are  all  to  be  recommended,  and 
should  be  used  if  scarification  is  declined  by  the  patient. 


CHAPTER  IX 

Surgical  Infective  Diseases  {Co7itinued) 

The  Venereal  Diseases^ 

gonorrhcea 

Gonorrhcea  is  an  acute  infective  inflammation  of  the  urethra  or 
vaginal  mucous  membrane,  sometimes  accompanied  by  complica- 
tions due  to  local  invasion,  to  auto-inoculation  of  the  mucous 
membranes,  or  to  invasion  of  the  lymphatics  or  blood.  One  attack 
is  not  protective. 

Etiology. — The  gonococcus  (Fig.  34)  is  the  infective  agent.     It 
occurs  in  pairs  or  groups  of  four  or  its  multiples,  and  is  present  in 

the  pus,  the  detached  epithelium  scales, 
and  in  the  intercellular  substance.  It  is 
somewhat  reniform,  the  concave  margins 
being  opposed.  It  is  cultivated  with  great 
difficulty,  and  stains  well  with  methyl-violet, 
but  not  by  Gram's  method.  The  organisms 
are  less  numerous  when  the  disease  has 
been  present  some  time.  A  similar  organ- 
ism is  sometimes  present  in  the  healthy 
urethra,  and  in  cases  of  gonorrhoea  the 
«  r.'^     \-      ,  ordinary  pyogenic  cocci  are  associated  with 

Fig.    34.  —  Gonococti   and   pus  y    jry     o 

cells.    (Drawn  by  G.  Col-   tlic    gonococcus.      It  is  probable   that  the 
pathological  effects  of   gonorrhoea  and   its 
complications  are  due  to  mixed  infection  with  the  gonococcus  and 
pyogenic  microbes. 

Some  people  are  more  susceptible  to  the  disease  than  are  others, 

1  It  has  been  considered  more  convenient  to  group  these  diseases  together, 
although  gonorrhcea  and  chancroid  may  be  regarded  as  local  diseases,  and  syphilis 
as  general. 


CH.  IX    SIGNS  AND  SYMPTOMS  OF  GONORRHCEA        157 

and  suffer  more  severely.  A  long  and  tight  foreskin,  hypospadias, 
and  uncleanliness  favour  infection.  The  tubercular,  rheumatic,  and 
gouty  are  liable  to  suffer  for  a  long  time,  and  to  be  affected  by  certain 
complications.  As  a  rule,  the  first  attack  of  gonorrhoea  is  the  most 
severe. 

Morbid  anatomy. — In  men  the  urethra,  especially  at  the 
fossa  navicularis  and  bulb,  is  the  seat  of  the  disease,  the  glans 
and  prepuce  often  participating.  In  women  the  vagina  and  vulva 
are  primarily  affected,  but  extension  to  the  urethra  is  common. 

The  organisms  invade  the  epithelium  cells,  pass  between  them 
into  the  deeper  structures,  and  may  then  spread  by  the  lymphatics. 
They  excite  acute  inflammation ;  the  mucous  membrane  acquires 
a  bright  red  colour,  and  is  swollen  and  highly  sensitive.  .  The 
epithelial  cells  proliferate,  and  some  of  them  becoming  detached, 
are  carried  away  by  the  copious  purulent  discharge  which  soon 
occurs.  Sometimes  flakes  of  lymph  cover  the  inflamed  surface, 
and  are  washed  away  by  the  urine,  or  the  process  may  be  so  intense 
that  phlyctenular  ulcers  and  erosions  occur,  which  may  be  the  seat 
of  subsequent  stricture  or  warty  growths.  The  inflammation 
gradually  extends  backwards,  but  is  often  arrested  at  the  bulb  or 
membranous  urethra ;  extension  to  the  lacunae  and  ducts  opening 
into  the  urethra  may  lead  to  perineal  abscess,  prostatis,  epididymitis, 
or  vesiculitis ;  if  the  erectile  tissue  of  the  corpus  spongiosum  is 
involved,  its  distensibility  is  diminished  by  bands  of  lymph,  and 
erection  is  consequently  imperfect  and  painful  (chordee).  Xxtension 
to  the  bladder  and  upper  urinary  tract  is  rare.  Involvement  of 
the  lymphatics  may  occasion  lymphangitis  and  bubo,  or  celluHtis 
in  women.  Gonorrhoeal  rheumatism  and  pyaemia  are  due  to  dis- 
semination of  the  poison  by  the  blood-stream,  through  involve- 
ment of  the  prostatic  plexus,  more  rarely  through  the  dorsal  vein. 
The  various  complications  thus  indicated  do  not  occur  with  equal 
frequency,  and  they  will  be  considered  in  due  course.  In  women 
similar  invasion  is  noticeable,  but  different  organs  are  necessarily 
involved.  The  cervical  canal  and  body  of  the  uterus,  the  Fallopian 
tubes,  ovaries,  and  pelvic  cellular  tissue  may  all  suffer,  and  doubt- 
less manv  cases  of  chronic  tubal  disease  and  ovaritis  are  due  to 
antecedent  gonorrhoea. 

SIGNS    AND    SYMPTOMS    OF    GONORRHCEA    IN    THE    MALE 

The  incubative  stage  is  usually  about  four  or  five  days,  but 
may  be  longer  or  shorter.      In  the  majority  of  cases  the  shorter  the 


158  MANUAL  OF   SURGERY  chap. 

incubation  the  more  severe  the  course  of  the  disease.  During  this 
period  the  patient  may  experience  some  frequency  of  micturition 
with  slight  scalding,  accompanied  by  swelling  and  itching  at  the 
meatus. 

When  the  acute  stage  comes  on,  the  itching,  redness,  and 
swelling  of  the  meatus  are  more  marked,  and  the  whole  penis  may 
be  slightly  swollen,  congested,  tender,  and  hot,  especially  along  the 
coipus  spongiosum.  ^Micturition  is  frequent,  and  accompanied  by 
smarting  and  burning  pain,  which  is  sometimes  very  severe.  For 
the  first  few  hours  the  discharge  is  scanty  and  watery,  but  soon 
becomes  copious,  thick,  and  creamy,  and  of  a  greenish  -  yellow 
colour.  The  urine  is  turbid  from  admixture  of  discharge,  and 
shreds  of  lymph  are  seen  floating  in  it.  Sometimes  blood,  pro- 
ceeding from  an  erosion,  may  escape  with  the  discharge ;  or 
haemorrhage  may  be  more  severe  and  constant  owing  to  rupture 
of  an  engorged  vessel  during  erection.  Painful  and  persistent 
erections  with  a  curved  condition  of  the  penis  are  common  at 
night ;  they  are  due  to  the  genital  irritation  and  the  curvature  to 
the  incomplete  distension  of  the  erectile  tissue  already  men- 
tioned. As  the  inflammation  extends  backwards  the  symptoms 
are  aggravated,  especially  if  the  prostatic  urethra  and  neck  of  the 
bladder  are  involved.  In  such  cases  the  frequent  and  painful 
attempts  at  micturition — only  a  few  drops  of  urine  being  voided  at 
each  attempt — may  be  very  distressing  and  alarming  to  the  patient, 
who  is  fearful  of  complete  retention  and  stricture.  The  congestion 
of  the  mucous  membrane,  swelling  of  the  veru-montanum,  and 
associated  spasm  of  the  peri-urethral  muscles  may  cause  retention. 
The  dorsal  lymphatics  are  often  enlarged  and  tender,  and  the 
superficial  inguinal  glands  may  participate,  but  rarely  suppurate.  In 
some  cases,  small,  nodular  and  tender  swellings  may  be  present  along 
the  urethral  canal ;  these  are  due  to  inflammation  of  the  lacunae, 
and  may  be  the  starting-point  of  peri-urethral  abscess.  Usually 
gonorrhoea  is  unaccompanied  by  general  disturbance  ;  but  some- 
times the  general  health  suffers,  especially  in  weakly  persons,  or  if 
pain  and  chordee  occasion  sleepless  nights.  Slight  fever  is  some- 
times present. 

The  acute  stage  passes  off  in  from  one  to  four  weeks,  according 
to  the  severity  of  the  attack.  The  local  signs  subside,  and  the  dis- 
charge becomes  less  copious  and  more  watery ;  it  may  disappear  in 
another  ten  days  or  so,  or  remain  indefinitely  as  a  gleet,  appearing 
in  the  early  morning  when  the  urethra  has  not  been  washed  out  by 
the  urine  for  some  hours. 


IX  SIGNS  AND  SYMPTOMS  OF  GONORRHCEA        159 

Prognosis. — Gonorrhcea  runs  its  course  in  about  a  month 
or  six  weeks,  but  if  the  patient  is  in  feeble  heakh,  or  neglects  the 
treatment  prescribed,  it  may  last  much  longer,  and  be  followed  by 
a  chronic  gleet.  A  narrow  meatus,  stricture,  previous  attacks,  and 
chronic  alcoholism  are  unfavourable  to  speedy  cure.  The  subject 
of  gleet  is  considered  under  Diseases  of  the  Urethra,  vol.  iii. 

Treatment. — General. — At  the  onset  of  the  disease  the  patient 
should  keep  as  quiet  as  possible,  and  if  the  attack  be  very  severe 
he  may  with  advantage  remain  in  bed.  Horse-  or  bicycle-riding  and 
all  forms  of  violent  exercise  must  be  prohibited.  The  bowels  should 
be  freely  acted  on  and  regulated  by  a  saline  aperient.  The  diet 
must  be  light,  plain,  and  unstimulating ;  malt  liquors,  alcohol,  coffee, 
tea,  sauces,  and  highly-seasoned  dishes  being  interdicted.  Milk, 
barley-water,  soda-water,  and  the  like  should  be  freely  taken.  If  the 
smarting  during  micturition  is  severe,  it  may  be  relieved  by  the  use 
of  the  carbonate  or  citrate  of  potash  with  tincture  of  hyoscyamus, 
by  hot  baths,  or  belladonna  suppositories ;  and  if  the  pain  be 
extreme,  10  minims  of  a  5  per  cent  solution  of  cocaine  may  be 
injected  into  the  urethra  before  micturition. 

During  the  acute  stage  much  relief  is  obtained  by  the  use  of 
the  hot  bath  night  and  morning,  the  patient  remaining  in  it  from 
ten  to  twenty  minutes.  Troublesome  chordee  should  be  treated  by 
the  administration  of  bromide  of  potassium  and  chloral  hydrate,  or 
by  the  use  of  the  hot  bath  before  the  patient  retires  to  rest,  followed 
by  a  suppository  of  three  grains  of  camphor  with  opium  or  bella- 
donna. The  painful  erection  is  immediately  relieved  by  immersing 
the  penis  in  cold  water. 

Strict  personal  cleanliness  must  be  observed,  and  an  antiseptic 
gonorrhoea-bag  should  be  worn  to  prevent  staining  of  the  linen  by 
discharge.  The  practice  of  placing  a  piece  of  Hnt  or  cotton  over 
the  end  of  the  penis  and  beneath  the  foreskin  for  this  purpose  is  to 
be  condemned.  A  suspender  should  be  worn.  The  patient  should 
always  be  warned  of  the  contagious  nature  of  his  discharge,  especi- 
ally with  regard  to  accidental  inoculation  of  the  conjunctiva. 

The  special  treatment  consists  in  the  administration  of  certain 
drugs  internally  and  topical  applications  by  urethral  injection,  thelatter 
being  the  most  important.  Internally  copaiba,  cubebs,  and  sandal 
oil  are  the  drugs  of  greatest  value,  though  they  are  uncertain  in  their 
action,  and  liable  to  cause  gastric  disturbance  and  dyspepsia.  They 
are  excreted  by  the  kidneys,  and  have  apparently  a  direct  effect  upon 
the  urethra.  These  drugs  are  specially  useful  when  the  acute  stage 
is  subsiding,  and  are  contra-indicated  during  that  stage.     Copaiba 


i6o  ■  MANUAL  OF  SURGERY  chap. 

has  the  disadvantage  of  sometimes  producing  an  extensive  irritable 
urticarial  rash,  perhaps  with  associated  constitutional  symptoms ; 
occasionally  cubebs  acts  in  a  similar  manner. 

Copaiba  is  best  given  in  capsules  on  account  of  its  nauseous 
taste  ;  a  small  dose  is  given  at  first,  for  fear  of  inducing  the  toxic 
symptoms  referred  to,  but  the  dose  may  be  gradually  increased  up 
to  30  minims  or  a  drachm  thrice  daily. 

Cubebs  is  more  likely  to  upset  the  digestion  than  is  copaiba ;  it 
is  best  administered  as  the  fresh-ground  powder,  one  teaspoonful  in 
a  little  warm  milk  being  taken  three  times  a  day  shortly  after 
meals. 

Sandal  oil  should  be  given  in  10-20  minim  doses,  contained 
in  capsules,  three  times  a  day.  It  is  less  irritating  and  more  easily 
borne,  but  also  more  uncertain  in  its  action,  than  copaiba  or  cubebs. 
All  these  drugs  must  be  persevered  with  and  taken  for  some  time 
before  being  discarded  as  useless. 

Turpentine,  Canada  balsam,  buchu,  uva  ursi,  quinine,  and  iron 
are  sometimes  useful  if  copaiba,  cubebs,  or  sandal  oil  cannot  be 
tolerated. 

Injections. — During  the  acute  stage,  when  there  is  much  con- 
gestion, copious  discharge,  and  severe  smarting,  the  urethra  should 
be  cleansed  three  or  four  times  a  day  by  the  injection  of  tepid  water. 
At  this  period  astringent  lotions  are  ill  borne,  and  may  materially 
aggravate  the  condition,  besides  being  very  painful.  The  perman- 
ganate of  zinc,  gr.  ^^  to  an  ounce  of  distilled  water,  is  very  mild 
and  most  useful ;  it  may  be  used  after  the  first  few  days. 

As  the  acute  stage  subsides  astringent  and  antiseptic  injections 
are  indicated.  It  will  often  be  found  that  an  injection  suiting  one 
case  is  unsuitable  for  another.  The  chloride  of  zinc,  gr.  ^,  ext. 
belladonna,  gr.  2  to  an  ounce  of  distilled  water,  is  a  useful  injection 
in  most  cases.  Sulpho-carbolate  of  zinc,  gr.  1-2  ;  sulphate  of  zinc, 
gr.  1-3  ;  tannic  acid,  gr.  i  ;  nitrate  of  silver,  gr.  |-J,  are  all  useful, 
and  may  be  combined  with  extract  of  belladonna  or  acetate  of  lead, 
gr.  1-2,  ad  gi.  Mercuric  chloride,  i  :  5000,  is  recommended  by 
some,  but  is  often  productive  of  more  harm  than  good,  as  it  is 
liable  to  cause  considerable  irritation.  Certain  preparations  of 
silver  are  now  much  in  vogue,  especially  on  the  Continent.  Argen- 
tamin,  largine,  itrol,  argonin,  and  protargol  are  the  preparations 
employed,  the  last,  introduced  by  Neisser,  being  the  most  favoured 
because  of  its  unirritating  properties  and  more  beneficial  action  as 
a  bactericide.  Protargol  contains  about  8  per  cent  silver  nitrate, 
and  should  be  used  as  a   i  per  cent  solution.     The  injections  are 


IX  SIGNS  AND  SYMPTOMS  OF  GOXORRHCEA        i6i 

made  thrice  daily,  being  retained  the  first  time  about  five  minutes, 
the  second  fifteen,  and  the  third  thirty.  The  treatment  must  be 
kept  up  for  about  a  month,  but  lessens  the  severity  of  the  disease 
and  prevents  its  extension  backwards.  The  advantages  claimed 
for  protargol  are  borne  out  by  experience,  although  some  cases 
prove  refractory.  In  chronic  cases  affecting  the  deep  parts  of  the 
urethra,  a  20-25  per  cent  solution  may  be  applied  topically  through 
the  endoscopic  tube  or  by  Guyon's  injector. 

Largine  (^-J  per  cent  solution)  is  said  to  be  as  useful  as 
protargol,  if  used  in  the  same  way.  In  obstinate  cases  the  in- 
jection of  the  four  sulphates  (alum  sulph.,  zinc  sulph.,  ferri  sulph., 
aa  gr.  20-30;  cup  sulph.,  gr.  2,  ad  5viii.)  may  be  tried. 

The  use  of  injections  is  contra-indicated  if  there  is  much  local 
congestion  and  irritation,  or  if  they  aggravate  the  local  condition 
and  cause  much  pain.  If  tolerated,  their  strength  may  be  slightly 
increased  about  every  four  or  five  days,  but  the  use  of  very  strong 
solutions  is  to  be  avoided.  When  the  membrano-prostatic  portion 
of  the  urethra  is  affected,  it  is  generally  necessary  to  apply  the 
lotions  topically  through  the  endoscopic  tube. 

Method  of  using  an  injection. — Injection  should  be  made  from 
three  to  six  times  a  day,  but  is  best  avoided  the  last  thing  at  night. 
Previous  to  injecting,  the  patient  should  empty  the  bladder,  and 
then  wash  out  the  urethra  with  a  syringeful  of  tepid  water.  About 
two  drachms  of  the  lotion  (slightly  warmed)  is  then  carefully  in- 
jected, and  retained  for  about  two  minutes  or  longer  by  holding 
the  glans  penis.  The  test  of  a  successful  injection  is  that  when 
the  fluid  is  allowed  to  escape  it  does  so  in  a  jet,  and  does  not 
merely  dribble  away. 

Irrigation  method. — Janet,  who  introduced  this  method,  claims 
that  it  is  superior  to  any  other  and  may  cut  short  the  disease  in 
from  five  to  seven  days.  This  plan  has  not  received  the  attention 
in  -the  country  which  it  merits ;  it  has  the  disadvantage  of  being 
troublesome  to  carry  out.  Janet  recommends  the  use  of  perman- 
ganate of  potash  solution,  1:4000  to  1:1000;  protargol  i  per 
cent,  and  itrol  i  :  4000,  are  also  highly  spoken  of  by  some.  The 
irrigation  is  performed  twice  daily,  with  the  weaker  solutions  to 
begin  with,  and  in  three  or  four  days  only  once  in  twenty-four 
hours  with  a  stronger  solution,  after  another  ten  days  irrigation  is 
carried  out  once  in  forty-eight  hours,  and  the  permanganate  solu- 
tion is  of  the  strength  i  :  1000.  The  fluid  is  introduced  by  gravity 
(the  vessel  holding  it  being  about  20-40  inches  above  the  penis, 
according  to  the  length  of  urethra  involved) ;  a  glass  cannula  is  held 

VOL.  I  M 


i62  MANUAL   OF   SURGERY  chap. 

within  the  canal,  and  about  one  to  two  pints  is  used  at  each  irriga- 
tion. If  congestion  of  the  urethra  is  caused,  the  strength  of  the 
solution  must  be  diminished.  The  test  of  the  cure  is  in  the 
absence  of  gonococci  from  the  discharge. 

Medicated  bougies  are  much  praised  by  some  surgeons,  but 
often  produce  irritation  without  any  proportionate  good.  The 
bougies,  composed  of  iodoform,  gr.  5,  eucalyptus  oil,  Tl\^io,  and 
cocoa  butter,  are  well  oiled  and  introduced  at  night,  a  gonorrhoea- 
bag  being  worn  to  prevent  soiling  of  the  linen.  A  bougie  may  be 
passed  each  night  for  a  week,  and  during  the  day  a  mild  astringent 
injection  should  be  used. 

The  abortive  treatment  of  gonorrhoea  is  not  to  be  recom- 
mended. It  consists  essentially  in  the  application  through  the 
endoscopic  tube  of  a  strong  solution  of  nitrate  of  silver  to  the 
inflamed  area,  with  the  internal  administration  of  large  doses  of  the 
resins.  This  treatment  is  attended  by  considerable  risk  of  severe 
inflammation. 


SIGNS    AND    SYMPTOMS    OF    GONORRHOEA    IN    THE    FEMALE 

The  entrance  of  the  vagina  and  the  vulva  are  the  parts  of 
primary  attack,  the  disease  spreading  upwards  towards  the  uterus, 
and  very  often  to  the  urethra.  In  women,  gonorrhcea  may  remain 
undiscovered  for  some  time,  since  there  is  often  no  pain  or  smarting 
on  micturition,  and  the  discharge  and  itching  induced  by  it  are 
attributed  to  leucorrhcea.  When  the  vulva,  and  especially  the 
nymph^e,  are  inflamed,  the  patient's  attention  is  quickly  aroused  by 
the  smarting  pain  on  micturition,  and  by  the  swelling  and  irritation 
about  the  parts,  coupled  with  the  profuse  greenish-yellow  discharge. 
On  examination  the  nymph^e  will  be  found  swollen  and  projecting, 
intensely  red,  and  perhaps  excoriated.  The  affected  mucous 
membrane  is  of  a  bright  red  colour,  congested,  swollen,  and 
exquisitely  tender,  so  that  a  thorough  examination  is  difficult. 
Phlyctenular  ulcers  and  erosions  may  be  present  in  bad  cases. 
The  discharge  is  ver)-  irritating,  often  highly  offensive,  and  comes 
from  the  vaginal  mucous  membrane  and  not  from  the  cer\-ix  uteri 
unless  this  be  involved.  If  the  urethra  is  affected,  discharge  can 
be  squeezed  out  of  it  by  drawing  the  finger  along  it  from  above 
down  ;  it  may  also  escape  from  the  orifices  of  Skene's  ducts,  which 
lie  close  to  the  meatus.  A  purulent  discharge  from  the  urethra 
is  practically  diagnostic  of  gonorrhoea,  as  inflammation  of  other 
origin  does  not  affect  this  canal.     The  acute  stage  usually  subsides 


IX  COMPLICATIONS  &  SEQUELS  OF  GONORRHCEA   163 

under  treatment  in  from  ten  to  fourteen  days.  If  the  disease 
becomes  chronic,  the  upper  part  of  the  vagina  and  the  cervix  are 
chiefly  affected. 

Diagnosis. — Leucorrhoea  may  be  distinguished  from  gonor- 
rhoea by  the  absence  of  acute  inflammation,  and  by  the  facts  that 
the  discharge  comes  from  the  cervix  uteri  and  not  from  the  vagina, 
and  that  the  urethra  is  not  involved.  If  gonorrhoea  spreads  to  the 
cervical  canal,  there  will,  in  addition  to  the  vaginal  discharge,  be  a 
purulent  discharge  from  it.  In  all  doubtful  cases  the  organism 
should  be  sought  for  with  a  view  to  clearing  the  patient's  reputation, 
or  in  view  of  future  legal  contingencies. 

Prognosis. — If  the  case  comes  under  treatment  early  the 
prognosis  is  good,  as  the  affected  parts  are  easy  of  local  treatment; 
but  if  it  has  been  neglected  and  become  chronic,  the  disease  is 
often  very  obstinate,  and  may  lead  to  grave  complications  to  be 
presently  mentioned. 

Treatment. — Topical  applications  m.ay  be  applied  by  means 
of  tampons,  which  may  be  retained.  They  are  practically  the  same 
as  those  recommended  for  injection  in  the  case  of  the  male. 

The  employment  of  rest,  hot  baths,  and  free  douching  of  the 
vagina  with  boracic  acid  (gr.  4,  ad  ^i.),  alum  (gr.  5,  ad  gi.),  or 
acetate  of  lead  (gr.  2,  ad  3!.)  will  speedily  allay  the  acute  symptoms. 
Severe  pain  may  necessitate  the  local  application  of  a  5  per  cent 
solution  of  cocaine.  Strict  personal  cleanliness  must  be  observed  ; 
the  nymphae  should  be  separated  by  a  piece  of  lint,  and  a  sanitary 
towel  worn.  If  the  urethra  is  affected,  balsamic  remedies  internally 
and  injections  locally  are  indicated. 

When  the  acute  symptoms  have  subsided,  any  local  inflammation 
and  patches  of  erosion  may  be  treated  through  the  speculum  by 
solutions  of  nitrate  of  silver,  glycerine  of  tannin,  or  zinc  salts.  They 
may  be  used  of  greater  strength  than  advised  for  urethral  injection. 
When  gonorrhoea  affects,  as  it  so  frequently  does,  the  cervical  canal, 
great  care  must  be  taken  that  this  receives  adequate  treatment,  or 
the  persistence  of  the  disease  may  lead  to  serious  after-consequences. 

COMPLICATIONS    AND    SEQUELS    OF    GONORRHCEA 

The  various  complications  do  not  occur  with  equal  frequency, 
and  some  people  are  more  liable  to  suffer  than  others.  Neglect  of 
due  care  during  treatment  favours  their  occurrence. 

Complications  common  to  the  sexes. —  Gonorphoeal 
ophthalmia. — Infection   of  the  conjunctiva  may  be  due   to  auto- 


1 64  MANUAL   OF  SURGERY  chap. 

inoculation,  but  occasionally  surgeons  are  inoculated  after  ex- 
amining a  gonorrhceal  case.  The  patient  should  always  be 
warned  of  this  danger.  The  disease,  which  runs  a  rapid  and 
destructive  course,  may  result  in  loss  of  the  eye  unless  prompt 
treatment  be  adopted,  and  is  accompanied  by  considerable  mental 
and  physical  depression.  Within  a  few  hours  of  inoculation  there 
is  smarting  pain  in  the  eye,  with  acute  congestion  of  the  conjunc- 
tiva, which  is  much  swollen  and  chemosed.  Very  soon  there  is 
copious  purulent  discharge,  distending  the  swollen  lids  and  dripping 
from  the  palpebral  fissure.  Pain  in  the  eye  and  round  the  orbit  is 
severe.  Unless  promptly  cut  short  the  cornea  is  implicated,  sup- 
puration and  sloughing  ensue,  and  the  entire  globe  may  be  lost. 
Iritis  and  sclerotitis  are  sometimes  met  with  in  association  with 
gonorrhceal  rheumatism. 

Treatment. — The  other  eye  must  be  covered  with  a  watch-glass 
let  into  a  piece  of  strapping,  which  is  fastened  along  the  brow  and 
nose.  Under  cocaine  or  a  general  anaesthetic  the  lids  must  be 
separated,  the  discharge  washed  away  with  boric  acid  solution,  and 
the  infected  surface  brushed  over  with  a  solution  of  silver  nitrate 
(gr.  20,  ad  51.);  in  a  few  minutes  the  superfluous  solution  should 
be  washed  away  with  water.  This  must  be  done  once  or  twice 
daily,  and  in  addition  the  eye  should  be  frequently  cleansed  with 
boric  acid  or  alum  lotion.  Protargol  is  recommended  by  Fiirst  as 
being  less  irritating  and  more  reliable  than  silver  nitrate.  Pain 
may  be  relieved  by  the  ice-bag,  or  morphia  may  be  given.  The 
general  treatment  must  be  of  a  tonic  and  stimulating  character,  in 
spite  of  the  urethral  discharge.  If  the  eye  sloughs  the  treatment 
for  panophthalmitis  must  be  employed. 

Pysemia  is  rare,  and  may  spread  from  infective  inflammation  of 
the  vaginal  or  prostatic  veins.  It  runs  the  ordinary  course  of 
pyaemia  from  other  causes,  and  is  probably  due  to  mixed  infec- 
tion. 

Gonorrhoea!  or  urethral  rheumatism. — In  the  great  majority 
of  cases  of  urethral  rheumatism  gonorrhuea  is  the  exciting  cause, 
but  it  may  arise  from  urethral  irritation  due  to  other  causes,  e.g. 
instrumentation.  Fournier  mentions  a  case  in  which  the  act  of 
coitus  was  always  followed  by  rheumatism  the  next  day,  independ- 
en.ly  of  any  infection. 

It  is  much  more  common  in  men  than  women,  and  especially  in 
those  of  a  rheumatic  or  gouty  tendency.  Exposure  to  cold,  chronic 
alcoholism,  and  previous  attacks  are  causative  agents.  When  once 
urethral  rheumatism  has  occurred  it  is  very  likely  to  reappear  with 


IX  COMPLICATIONS  &  SEQUEL.'E  OF  GONORRHOEA   165 

any  fresh  irritation  or  gonorrlucal  infection,  and  relapses  are  very 
common.  Emery  has  recorded  the  case  of  a  man  who  had  nineteen 
attacks,  with  ten  attacks  of  gonorrhoea. 

Patholo^^y  and  7?wrl)id  anatojjiy. — It  is  probable  that  all  cases  of 
urethral  rheumatism  are  not  due  to  the  same  pathological  change. 
I'hose  of  gonorrhceal  origin  are  probably  pygemic,  and  the  gono- 
coccus  has  been  found  in  the  synovial  effusion.  Some  think  that 
the  central  nervous  system,  especially  the  medulla,  is  affected 
reflexly ;  whilst  others,  without  much  apparent  reason,  consider 
these  cases  to  be  of  the  nature  of  simple  rheumatism. 

The  disease  affects  the  larger  joints,  large  fascial  planes,  peri- 
articular siructures  and  ligaments,  and  occasionally  the  large  nerve 
trunks,  the  sclerotic  coat  of  the  eye,  etc.,  but  very  rarely  the  heart.  The 
inflammatory  change  in  the  joints  is  essentially  chronic,  although 
marked  by  an  acute  onset ;  it  attacks  the  knee  joint  more  often 
than  any  other,  although  many  may  suffer.  After  repeated  attacks 
the  small  joints  of  the  fingers  are  sometimes  permanently  deformed, 
as  in  rheumatoid  arthritis. 

The  peri-articular  structures  are  infiltrated,  and  oedema  often 
extends  some  distance  beyond  the  joint ;  the  synovial  membrane 
becomes  thickened,  and  there  is  an  increase  in  the  amount  of 
fluid.  Suppuration  is  very  rare  ;  more  usually  the  disease  becomes 
chronic,  the  fluid  is  gradually  absorbed  and  repair  ensues.  Fibrous 
adhesion  causing  more  or  less  complete  ankylosis  is  occasionally 
found  and  is  especially  likely  to  occur  after  repeated  attacks. 
Tendon  sheaths  and  bursge  may  be  similarly  affected,  and  cases 
have  been  recorded  in  which  disseminated  muscular  atrophy  was 
present  (Gaston). 

Signs. — Gonorrhoea!  rheumatism  does  not  usually  come  on  until 
after  the  third  week  of  the  disease,  when  the  inflammation  has 
extended  backwards  to  the  membrano-prostatic  urethra.  It  may, 
however,  occur  wdthin  a  few  days,  especially  in  recurrent  attacks. 
At  the  onset  the  urethral  discharge  usually  abates  considerably  and 
may  temporarily  disappear.  The  patient  feels  ill  and  depressed, 
and  there  is  more  or  less  fever,  with  general  malaise  and  pains 
about  the  body  and  limbs ;  yet  sometimes  there  is  practically  no 
constitutional  disturbance.  Occasionally  pain  in  the  affected 
joints  is  the  only  symptom ;  more  usually  this  is  accompanied  by 
hydarthrosis  which  may  be  very  persistent,  partially  clearing  up  at 
times  only  to  relapse.  In  severer  cases  the  peri-articular  and 
ligamentous  structures  are  involved,  occasioning  much  pain,  swell- 
ing,   and    constitutional    disturbance,    and    perhaps    resulting    in 


1 66  MANUAL  OF  SURGERY  chap. 

permanent  stiffness.  If  more  than  one  joint  is  involved,  the  disease 
is  more  serious  and  the  patient's  constitutional  condition  proportion- 
ately grave.  The  ankles,  wrists,  and  elbows  are  often  affected,  the 
temporo- maxillary  and  sterno- clavicular  articulations  not  infre- 
quently, and  no  joint  is  exempt. 

Severe  pain  may  be  experienced  in  the  plantar  or  palmar 
fascia,  along  the  ilio-tibial  band  or  large  aponeuroses.  The 
sciatic  nerve  and  sometimes  other  large  trunks  may  be  the  seat  of 
more  or  less  severe  neuralgia. 

The  disease  is  sometimes  complicated  by  sclerotitis  and  iritis. 

Diagnosis. — The  presence  of  a  urethral  discharge,  or  in  default 
of  this,  the  detection  of  shreds  in  the  urine ;  the  obstinacy  of  the 
joint  affection  and  the  limitation  of  the  disease  to  one  or  two 
joints,  with  perhaps  implication  of  the  nerves  and  fasciae,  and  the 
slight  constitutional  disturbance,  will  usually  lead  to  a  correct 
diagnosis.      The  ordinary  signs  of  acute  rheumatism  are  absent. 

Prognosis. — If  the  patient  is  young  and  has  previously  enjoyed 
good  health,  the  prognosis  is  good,  but  the  disease  is  often  very 
chronic,  may  last  as  long  as  six  months,  and  usually  does  so  for 
as  many  weeks.  Previous  attacks  are  unfavourable  not  only  to 
the  duration  of  the  disease,  but  to  the  complete  recovery  of  the 
affected  joints.  Suppuration  is  very  rare,  fibrous  ankylosis  the 
exception,  and  resolution  the  rule.  Those  broken  down  in  general 
health  and  with  a  marked  gouty  or  rheumatic  tendency  are  liable 
to  suffer  severely. 

Ti'eatment. — The  primary  indication  is  to  cure  the  urethral 
disease,  for  so  long  as  this  remains,  gonorrhoeal  rheumatism  will 
prove  intractable. 

As  regards  the  rheumatism,  the  patient  must  remain  in  bed  and 
the  affected  joints  be  kept  at  perfect  rest  by  the  application  of 
splints  or  other  means  suitable  to  the  articulation.  If  the  in- 
flammation is  very  acute  and  accompanied  by  much  pain  and 
effusion,  hot  fomentations  or  repeated  blisters  should  be  applied, 
or  the  fluid  may  be  removed  by  aspiration.  If  the  course  be  more 
chronic,  strapping  with  Scott's  ointment  is  the  best  treatment,  to 
be  followed,  when  all  active  symptoms  have  subsided,  by  massage, 
friction,  and  gentle  passive  movement.  The  bowels  should  be 
acted  on  by  saline  aperients,  and  the  secretion  of  urine  favoured  by 
diuretics.  Salicylates  are  usually  of  no  avail.  The  most  useful 
drugs  are  iron,  quinine,  and  iodide  of  potassium,  combined  with 
cod-liver  oil  and  tonics. 

The  diet  must   be  light  but    generous,   and   in   spite   of   the 


IX  COMPLICATIONS  &  SEQUELS.  OF  GONORRHCEA   167 

urethral  mischief,  a  little  wine  is  usually  advisable  in  the  depressed 
state  of  the  patient. 

When  the  patient  is  able  to  be  moved  without  fear  of  a  relapse 
he  may  advantageously  go  to  Buxton,  Bath,  or  Droitwich  for 
further  treatment,  or  may  take  a  sea  voyage. 

Cystitis,  pyelitis,  and  nephritis  are  rare  complications,  and  are 
dangerous  owing  to  the  infective  nature  of  the  mischief. 

Sympathetic  bubo. — Sometimes  the  inguinal  glands  are 
slightly  enlarged  and  tender,  but  suppuration  is  rare.  Should  it 
occur,  the  treatment  is  the  same  as  for  bubo  from  any  other  cause. 
It  is  more  common  in  men  than  women. 

Warts  of  the  prepuce  and  glans  penis  or  of  the  vulva  are 
frequently,  though  by  no  means  always,  due  to  gonorrhoea.  In  the 
male,  urethral  warts  may  form  at  the  site  of  an  erosion. 

Complications  peculiar  to  the  male  sex. — Balanitis  and 
balano-posthitis. — Inflammation  of  the  prepuce  and  glans  penis 
may  occur,  especially  if  the  former  is  tight  and  redundant. 

Inflammatory  phimosis  or  paraphimosis. — These  complica- 
tions are  very  common  in  the  uncleanly,  especially  if  they  have  long 
and  tight  foreskins. 

Periurethral  abscess  is  usually  due  to  the  extension  of  in- 
flammation along  one  of  the  lacunae.  The  gonococcus  finds  its 
way  into  the  peri-urethral  tissue  and  abscess  results.  It  is  not  a 
common  complication. 

Inflammation  of  the  neck  of  the  bladder  does  not  usually 
come  on  until  fourteen  days  or  later  from  the  time  of  infection.  It 
is  always  associated  wuth  inflammation  of  the  prostatic  urethra. 
This  condition  is  often  incorrectly  spoken  of  as  "cystitis."  The 
leading  symptoms  are  frequent  micturition  with  much  pain  and 
strangury ;  a  little  blood  may  be  passed,  and  the  urine  is  often 
turbid  from  admixture  of  discharge.  The  treatment  consists  in  the 
administration  of  salines  and  alkalis  with  hyoscyamus,  the  use  of 
the  hot  hip-bath,  and  of  morphia  or  belladonnra  suppositories. 

Prostatitis,  sometimes  resulting  in  acute  abscess,  may  occur 
from  extension  along  the  ducts.  In  other  cases  the  prostate  is 
chronically  congested,  slightly  enlarged,  and  tender,  giving  rise  to 
persistent  gleet.  Prostatic  involvement  does  not  usually  occur 
before  the  third  week. 

Epididymitis  is  one  of  the  commonest  complications  of  gonor- 
rhoea, and  occurs  at  the  end  of  or  later  than  the  third  week.  It 
is  due  to  direct  extension  along  the  vas  deferens,  and  is  usually 
unilateral,  but  may  affect  both  sides. 


1 68  MANUAL   OF   SURGERY  chap. 

Inflammation  of  the  vesieulse  seminales  sometimes  occurs. 

Hsemorrhage  from  the  urethra  may  occur  from  a  granular  patch 
and  is  then  shght  in  amount.  When  more  severe  and  persistent  it 
may  come  from  rupture  of  a  congested  vein  during  chordee.  In 
the  latter  case  the  bleeding  soon  ceases  if  the  patient  keeps  quiet 
and  bathes  the  penis  in  cold  water ;  should  it  continue,  an  injection 
of  tincture  of  hamamelis  (ll]^2o  ad  ^i.)  may  be  necessary. 

Congestive  and  spasmodic  retention  of  urine  is  sometimes 
occasioned  when  the  inflammation  is  very  acute  and  affects  the 
membrano-prostatic  urethra.  An  organic  stricture  may  also  become 
temporarily  occluded  through  congestion.  The  patient  should  be 
placed  in  a  hot  bath  and  encouraged  to  pass  his  urine  in  it ;  the 
bowels  should  be  acted  on,  and  rest  and  morphia  suppositories  with 
repeated  baths  usually  relieve  the  trouble  in  a  few  hours.  In  bad 
cases  a  soft  india-rubber  catheter  should  be  carefully  passed. 

Gleet  and  organic  stricture  may  follow  acute  gonorrhoea. 

Complications  peculiar  to  the  female  sex. — Abscess  of 
the  glands  of  Bartholin  is  not  uncommon. 

Pelvie  cellulitis  may  oeeur,  especially  in  cases  accompanied  by 
ulceration. 

Involvement  of  the  uterus,  ete. — Gonorrhcea  may  spread 
upwards  to  the  cervix  or  body  of  the  uterus,  to  the  Fallopian  tubes 
leading  to  pyosalpinx,  to  the  ovaries  and  broad  ligaments,  and 
occasionally  to  the  peritoneum.  These  complications  are  necessarily 
serious  and  frequently  lead  to  chronic  trouble. 

SYPHILIS 

Definition. — Syphilis  is  a  chronic  generalised  infective  disease 
with  prolonged  stages,  manifesting  its  action  by  setting  up  pecu- 
liar inflammatory  changes  in  various  parts  of  the  body,  more  especi- 
ally the  cutis,  but  also  other  more  deeply  placed  connective  tissue 
structures,  so  that  every  organ  and  tissue  is  liable  to  be  attacked  at 
some  period  during  the  evolution  of  the  disease. 

Syphilis  presents  its-lf  in  two  forms — (i)  the  acquired,  in  which 
inoculation  has  occurred  any  time  after  birth;  and  (2)  the  heredi- 
tary, in  which  the  foetus  has  become  infected  in  utero.  These  two 
forms  will  be  separately  considered,  since  the  hereditary  disease 
presents  important  differences  in  its  course. 

Etiology. — The  poison  of  syphilis  can  only  be  communicated 
by  contagion,  and  not  by  infection  through  the  air.  The  contagion 
may  also  be  transmitted  to  the  offspring  (heredo-contagion).     That 


IX  ACQUIRED  SYPHILIS  169 

the  poison  is  a  microparasite  there  can  be  little  doubt ;  but,  although 
Lustgarten  and  many  other  observers  have  described  organisms 
which  they  claim  to  be  the  contagium  vivuni  of  syphilis,  it  must,  for 
the  present,  be  admitted  that  the  evidence  in  support  of  these  claims 
is  inconclusive.  Syphilis  is  peculiar  to  man.  As  yet  the  disease 
has  not  been  recognised  in  the  lower  animals ;  and  although  it  is 
true  that  Disse  and  Taguelic  have  reported  the  effects  of  inoculating 
rabbits,  sheep,  and  dogs  with  the  cultures  of  a  micrococcus  found 
by  them  in  syphilitic  sores,  which  produced  chronic  interstitial  in- 
flammation of  the  lungs  and  liver,  fatty  changes  in  the  vessels,  and 
granulomatous  growths  similar  to  those  met  with  in  syphilis,  yet 
there  was  no  definite  proof  that  the  animals  had  been  rendered 
syphilitic.  Whatever  the  poison  may  eventually  prove  to  be,  it  is 
contained  in  the  secretions  from  the  primary  and  secondary  lesions, 
and  in  the  blood,  but  is  not  present  during  the  tertiary  period.  It 
is  practically  certain  that  the  normal  physiological  secretions  do  not 
contain  the  poison,  and  therefore  can  only  convey  the  disease  when 
they  are  mixed  with  inoculable  discharge  from  a  syphilitic  lesion, 
e.g.  the  saliva  when  the  throat  or  mouth  is  affected. 

Syphilis  has  no  relation  to  any  other  venereal  disease,  although 
it  was  formerly  held  by  some  that  all  such  were  simply  different 
clinical  manifestations  of  one  and  the  same  poison.  Hutchinson 
considers  that  many  of  the  non-syphilitic  sores  are  really  abortive 
manifestations  of  that  disease.  It  is  to  be  remembered  that  an 
ordinary  soft  chancre  may  also  be  inoculated  with  the  syphilitic 
poison  (mixed  chancre). 

As  with  other  infective  diseases,  so  with  syphilis,  some  people 
prove  more  or  less  resistant  to  the  poison,  while  others,  especially 
such  as  are  the  subjects  of  chronic  alcoholism,  renal  disease,  tuber- 
culosis, and  similar  conditions  which  diminish  the  general  resisting 
powers  of  the  body,  suffer  severely,  and  the  disease  may  run  a  very 
rapid  course  (malignant  and  galloping  syphilis). 

ACQUIRED    SYPHILIS 

Modes  of  contagion. — The  poison  may  be  conveyed  by  direct 
or  mediate  inoculation  through  an  abrasion  or  wound,  but  has  prob- 
ably no  injurious  effect  when  it  is  brought  in  contact  with  an  un- 
injured surface. 

Direct  inoculation  is  the  most  common,  and  usually  occurs  on 
the  genital  organs  during  sexual  intercourse ;  but  the  poison  may 
also  be  communicated  by  the  fingers,   by  kissing,  by  the  inocula- 


1 70  MANUAL  OF   SURGERY  chap. 

tion  of  a  child's  lip  by  a  syphilitic  nipple,  or  by  unnatural  sexual 
acts. 

Indirect  op  mediate  inoculation  may  occur  through  the  medium 
of  spoons,  cups,  pipes,  etc.,  which  have  been  used  by  a  patient  with 
secondary  lesions  in  the  mouth.  The  Eustachian  catheter,  probes, 
sponges,  and  surgical  instruments  must  also  sometimes  be  held  re- 
sponsible. In  rare  instances,  chiefly  on  the  Continent,  vaccination 
has  been  the  means  of  contagion,  and  thus  great  numbers  in  a  com- 
munity have  been  affected.  Vaccine  lymph  does  not  contain  the 
poison,  and  can  only  convey  syphilis  when  it  is  mixed  with  blood ; 
hence  such  lymph  should  never  be  used,  even  when  the  donor  is 
apparently  healthy.  Doubtless  many  cases  of  syphilis  in  infants, 
which  have  been  attributed  to  vaccination,  are  really  instances  of 
the  hereditary  disease,  which  has  only  declared  itself  after  vaccina- 
tion. Skin-grafting  has  also  conveyed  infection,  and  therefore  grafts 
should  always  be  taken  from  the  patient  needing  them  and  not  from 
an  intermediary. 

Symptomatolo^. — Syphilis  bears  a  close  analogy  to  the 
specific  exanthems,  but  differs  from  them  in  its  very  prolonged  course 
with  intervals  of  apparent  restoration  to  complete  health,  in  the 
possible  universal  distribution  of  its  pathological  effects,  in  its  multi- 
farious lesions,  and  in  its  amenability  to  specific  treatment ;  it  is, 
moreover,  contagious,  but  not  infectious.  Like  the  exanthematous 
fevers,  syphilis  has  a  definitive  incubative  period,  a  stage  of  efPxor- 
escence,  and  one  of  decline.  Like  them,  also,  one  attack  is  almost 
always  protective ;  but  should  the  patient  become  reinfected,  as 
occasionally  happens,  the  disease  either  aborts  or  runs  a  very  much 
less  severe  course. 

The  classification  of  syphilitic  manifestations,  in  common  use,  is 
chiefly  founded  upon  the  order  of  their  evolution.  The  disease 
passes  through  primary,  secondary,  latent,  and  tertiary  stages, 
but  the  division  between  these  is  to  some  extent  purely  arbitrary, 
for  the  symptoms  of  each,  especially  in  bad  cases  and  in  those  im- 
perfectly treated,  may  overlap.  Thus  symptoms  which  are  commonly 
met  with  in  the  later  stages  of  the  evolution  of  the  disease  occur  at 
an  early  period,  or  "precociously,"  In  mild  cases,  when  the  patient 
is  refractory  to  the  poison,  and  especially  those  in  which  mercurial 
treatment  has  been  begun  early  and  has  been  pushed,  the  secondary 
stage  and  those  subsequent  to  it  may  be  completely  suppressed, 
although  such  a  happy  event  is  rare,  and  the  patient  usually  suffers 
from  some,  although  perhaps  slight,  secondary  lesions. 

At  the  end  of  the  period  of  incubation  the  primary  lesion  makes 


IX  ACQUIRED  SYPHILIS  171 

its  appearance,  and  lasts  usually  about  six  or  eight  weeks.  Before 
this  has  passed  away  the  secondary  symptoms  appear,  and  may 
manifest  themselves  slightly  or  severely,  and  remain  intermittently 
or  persistently  present  for  one  or  two  years,  to  be  followed  at  a  vary- 
ing interval  of  time,  or  overlapped,  by  the  tertiary  phenomena. 
These  may,  however,  never  occur,  or  may  do  so  many  years  after  the 
patient  has  apparently  been  restored  to  complete  health,  the  interval 
not  having  been  marked  by  any  symptoms  referable  to  syphilis.  In 
other  cases  the  secondary  and  tertiary  stages  are  separated  by  a 
varying  interval  of  time,  during  which  the  patient  may  have  had 
occasional  symptoms  or  "  reminders  "  (latent  stage). 

The  primary  stage  usually  lasts  about  ten  or  twelve  weeks, 
and  comprises  the  incubative  period,  the  appearance  of  the  initial 
lesion  at  the  seat  of  inoculation,  and  the  associated  indolent  en- 
largement and  induration  of  the  lymphatic  glands  in  its  neighbour- 
hood. 

The  incubative  period  is  usually  from  twenty-four  to  twenty-eight 
days ;  it  may,  however,  be  shorter  or  longer,  but  is  very  rarely 
prolonged  beyond  six  weeks.  During  this  period  nothing  abnormal 
may  be  noticed,  and  any  abrasion  through  which  inoculation  has 
occurred  may  heal  soundly  without  trouble ;  in  other  cases  healing 
does  not  take  place.  If  the  patient  has  simultaneously  contracted 
a  soft  sore,  this  may  run  its  normal  course,  its  base  indurating, 
however,  when  the  incubative  stage  of  syphilis  has  passed. 

At  the  end  of  the  incubative  period  the  first  clinical  manifesta- 
tion of  the  disease  occurs  at  the  point  of  inoculation.  This  is  the 
ijiitial  lesion  or  Hunterian  chaticre  ;  it  is  always  present,  but  from  its 
situation  may  be  overlooked  or  not  diagnosed  as  a  chancre ;  or  its 
characters  may  be  masked  by  the  occurrence  of  phagedena,  the 
presence  of  soft  sores,  herpes,  or  some  other  source  of  irritation  and 
inflammation ;  lastly,  it  may  have  healed  before  the  patient  comes 
for  advice,  and  its  position  be  only  indicated  by  induration  of  the 
tissues  and  enlargement  of  the  adjacent  lymphatic  glands. 

The  primary  sore  is  usually  single,  but  occasionally  two  or  more 
are  present.  It  is  usually  situated  on  the  genital  organs,  but  may 
be  found  anywhere,  according  to  the  manner  of  inoculation. 
Extra-genital  sores  may  be  difficult  to  diagnose,  since  they  have 
often  been  treated  under  a  misapprehension  of  their  nature  and 
their  characters  thereby  altered.  In  doubtful  cases,  the  surgeon 
should  regard  with  suspicion  any  intractable,  indurated  sore  with 
enlargement  and  induration  of  the  neighbouring  lymphatic  glands, 
and  should  search  carefully  for  secondary  affections  of  the  skin  and 


172  MANUAL   OF   SURGERY  chap. 

mucous  membranes.  In  women  a  primary  sore  of  the  vagina  or 
on  the  OS  uteri  may  readily  escape  detection. 

A  primary  chancre  does  not  ahvays  present  the  same  features, 
but  there  are  certain  essential  characteristics  constantly  present. 
Circumscription,  dense  induration,  painlessness,  and  involvement  of 
the  lymphatics  and  glands  are  constant.  In  most  cases  the  sore 
appears  as  an  indurated  ulcer  or  erosion,  having  a  gristly  cartila- 
ginous feeling,  and  exuding  a  slight,  sticky,  highly  contagious  dis- 
charge which  is  never  profuse  or  purulent  unless  the  sore  be 
irritated.  Sometimes  the  whole  glans  penis  or  prepuce  is  the  seat 
of  general  induration  with  patches  of  diffuse  ulceration.  A  chancre 
occurring  on  the  sheath  of  the  penis  or  elsewhere  on  the  skin,  and 
if  unirritated,  is  not  accompanied  by  ulceration  or  loss  of  substance, 
but  takes  the  form  of  a  dense,  hard,  localised,  and  slightly  raised 
papule,  with  a  few  dry  scales  of  epithelium  on  the  surface.  Should 
such  a  sore  be  irritated,  it  will  break  down  and  form  an  indolent 
ulcer  seated  on  a  broad  base  of  cartilaginous  hardness.  As  a  rule, 
in  whatever  form  the  primary  chancre  appears,  it  gives  no  trouble ; 
but  if  irritated,  acute  inflammation  with  suppuration  and  perhaps 
phagedasnic  characters  may  ensue.  The  primary  lesion  may  heal 
spontaneously,  and  rapidly  does  so  under  mercurial  treatment ;  the 
seat  of  it,  however,  may  break  down  again  even  after  a  long  time. 
After  healing  there  is,  if  ulceration  has  occurred,  a  small  cicatrix, 
and  the  induration  persists  for  some  time. 

About  a  week  after  the  appearance  of  the  initial  sore,  the 
lymphatic  vessels  leading  from  it  are  enlarged  and  cordy  and  the 
neighbouring  glands  become  indurated.  The  glands  are  slightly 
enlarged,  but  quite  painless  ;  they  remain  discrete,  since  peri-adenitis 
is  not  excited.  Suppuration  never  occurs  unless  some  other  poison, 
e.g.  that  of  chancroid,  is  present. 

The  enlargement  of  the  glands  attains  its  maximum  in  two  or 
three  weeks  and  may  persist  for  many  months.  The  changes  in 
the  lymphatic  system  are  due  to  an  increase  in  the  fibrous  and 
cellular  elements. 

The  secondary  or  exanthematous  stage  may  last  as  long  as 
two  years,  but  rarely  does  so  more  than  one.  The  lesions  have  a 
natural  tendency  to  spontaneous  cure,  and  rapidly  disappear  under 
mercurial  treatment.  The  symptoms  appear  when  the  poison  has 
induced  general  toxaemia,  being  disseminated  throughout  the  body 
by  the  blood-stream,  and  has  had  sufficient  time  to  induce  patho- 
logical changes  in  the  various  tissues  —  that  is,  in  about  ten 
weeks  from   the   date    of   infection,   and   six  from  the  appearance 


IX  ACQUIRED   SYPHILIS  173 

of  the   primary  lesion  ;  but  this  stage   may  be  postponed   for   six 
months. 

The  secondary  symptoms  vary  much  in  severity,  and,  as  has 
already  been  mentioned,  may  in  favourable  cases  be  entirely,  or 
almost  entirely,  suppressed.  During  this  stage,  and  for  some  time 
after  it,  the  patient  is  capable  of  conveying  infection,  but  not  of  being 
himself  reinfected.  Preceding  the  appearance  of  the  lesions  charac- 
terising this  stage  in  the  evolution  of  the  disease,  there  is  often, 
especially  in  women  and  weakly  subjects,  general  malaise,  anorexia, 
and  headache,  with  rheumatoid  pains  in  the  back  and  limbs.  There 
may  be  some  fever  of  a  continuous  or  remittent  type  which,  in  rare 
cases,  is  very  severe,  and  simulates  typhoid.  Fever  is,  however, 
more  likely  to  occur  with  the  appearance  of  the  papular  eruption. 
Anemia  from  destruction  of  the  red  cells  is  constant,  and  may  by 
itself  prove  a  serious  condition.  Loss  of  fat  and  mental  dejection 
are  not  uncommon.  The  manifestations  of  secondary  syphilis  chiefly 
consist  of  certain  eruptions  of  the  skin,  analogous  conditions  of  the 
mucous  membranes,  and  affections  of  the  hair,  nails,  eyes,  and  bones. 
The  skin  is  especially  affected  by  eruptions  of  the  most  varying 
clinical  appearances  (syphilodermata  or  syphilides),  thus  they  may  be 
macular,  papular,  vesicular,  pustular,  nodular,  etc.  Such  eruptions  have 
certain  peculiar  characters  indicative  of  their  syphilitic  origin  (see 
p.  177).  The  syphilides  of  the  secondary  stage  are  more  superficial, 
more  copious,  more  symmetrically  arranged,  and  not  so  prone  to  ulcer- 
ate as  are  those  which  occur  during  the  tertiary  period  of  the  disease. 
Mucous  tubercles  or  condylomata  occur  at  the  muco-cutaneous  sur- 
faces, or  in  certain  parts,  e.g.  the  vulva,  nates,  and  axillae ;  these  are 
merely  the  ordinary  skin  lesions  modified  by  warmth  and  moisture 
consequent  on  their  position  (Fig.  35,  p.  180).  The  appendages  of 
the  skin  may  also  suffer  from  want  of  nutrition,  the  hair  falls,  and  the 
nails  may  become  brittle  and  furrowed,  and  the  matrix  may  inflame. 
The  mucous  membranes,  especially  of  the  mouth  and  throat,  are 
also  affected  by  the  eruption,  which,  in  these  situations,  give  rise  to 
mucous  tubercles,  condylomata,  or  superficial  grayish,  often  reniform, 
ulcers.  General  enlargement  of  the  lymphatic  glands  is  sometimes 
seen.  The  glands  do  not  suppurate,  neither  do  they  indurate,  as  in 
the  case  of  those  associated  with  the  primary  lesion ;  they  are 
slightly  tender. 

Iritis  is  by  no  means  uncommon,  and  usually  appears  with  the 
decline  of  the  eruption  ;  it  is  not  infrequently  bilateral,  and  in  some 
cases  there  may  be  associated  choroiditis,  retinitis,  or  optic  neuritis. 
Inflammation  of  the  periosteum  of  an  acute  or  sub-acute  nature  may 


174  MANUAL  OF  SURGERY  chap. 

occur  during  the  secondary  stage  ;  but  it  is  always  transient,  and  has 
no  tendency  to  cause  suppuration  or  death  of  the  underlying  bone, 
as  is  so  frequently  the  case  in  the  tertiary  stage.  The  joints,  bursae, 
and  synovial  sheaths  may  also  transiently  inflame,  sometimes  with 
considerable  effusion  of  fluid.  Neuralgic  pains,  which  are  worse  at 
night,  are  often  experienced  in  the  muscles,  bones,  and  joints  (syphi- 
litic rheumatism).  Syphilitic  changes  in  the  arterial  system,  especi- 
ally affecting  the  intima  of  the  vessels,  are  more  likely  to  occur 
during  this  stage  than  at  any  other  time  throughout  the  disease. 
Affections  of  the  nervous  system  (endarteritis,  meningitis)  may  be 
met  with,  and  it  is  noticeable  that  nervous  lesions  are  especially  liable 
to  occur  during  the  second  year  from  the  date  of  infection.  The 
viscera  are  rarely  affected,  but  they  may  be  the  seat  of  slight  inter- 
stitial inflammation. 

The  latent  period  or  period  of  relapses  may  be  very  prolonged 
even  to  as  much  as  twenty  or  thirty  years.  During  this  period  the 
patient  may  enjoy  perfect  health  and  may  never  sho\v  any  evidences 
of  the  disease,  but  sometimes,  especially  if  he  should  fall  into  ill- 
health,  "relapses"  or  "reminders"  make  their  appearance.  Such 
symptoms  usually  take  the  form  of  superflcial  and  often  painful 
fissures  or  ulcers  of  the  mucous  membrane  of  the  tongue  or 
cheeks,  or  of  skin  eruptions  similar  to  those  which  may  be  met 
with  during  the  secondary  stage,  but  being  less  profuse,  more 
hmited  as  regards  the  area  of  skin  involved,  and  showing  much  less 
symmetry  in  their  distribution. 

The  tertiary  stage. — "  By  tertiary  syphilis  is  meant  those 
manifestations  of  the  disease  which  are  characterised  (as  distinct 
from  the  secondary  symptoms)  by  the  deposition  of  a  syphilitic 
product,  deep  in  the  skin  or  mucous  membranes,  in  internal  organs, 
in  the  nervous  system,  in  bones,  blood-vessels,  or  muscles,  and 
which,  setting  apart  the  diff"erent  macroscopic  forms  in  which  they 
appear,  agree  in  not  tending  to  resolution,  but  in  leaving,  through 
sloughing  or  ulceration,  or  organisation  into  fibrous  tissue,  per- 
manent changes  which,  in  the  form  of  scars  or  contraction  of  the 
tissue,  lead  to  consequences  more  or  less  serious  according  to 
their  situation  "  (Haslund). 

The  real  nature  of  tertiaries  is  disputed;  Hutchinson  regards 
them  as  sequelae,  comparable  to  such  as  may  occur  after  any  other 
exanthematous  fever,  e.g.  scarlet  fever,  and  others  think  they  are 
the  outcome  of  a  specific  cachexia  produced  by  the  saturation  of 
the  system  with  the  syphilitic  toxine.  That  tertiaries  are  not 
dependent    upon   the   action   of   the  syphilitic  germs   which   have 


IX  ACQUIRED   SYPHILIS  175 

remained  dormant  for  a  long  period  until  circumstances  favour 
their  activity,  seems  to  be  indicated  by  the  fact  that  during  this 
stage  the  patient  is  incapable  of  conveying  infection,  unless  we  arc 
prepared  to  suppose  that  such  germs  have  undergone  some  change 
whereby  they  are  inimical  to  the  host  himself,  but  are  incapable  of 
producing  syphilis  in  another. 

Whereas  in  the  secondary  stage  the  patient  can  convey  the 
contagion  to  others  and  to  his  offspring,  but  is  immune  to  fresh 
infection,  in  the  tertiary  he  cannot  transmit  the  disease,  but  may 
acquire  a  fresh  dose  of  poison  (reinfection) ;  moreover,  the  second- 
ary lesions  tend  to  spontaneous  cure,  while  tertiary  symptoms  tend 
rather  to  persist  and  spread,  and  do  not  show  that  symmetrical 
arrangement  which  is  so  characteristic  of  the  secondary  stage. 

Tertiary  symptoms  may  occur  any  time  after  two  or  three  years 
from  the  date  of  infection ;  the  essential  feature  of  this  stage 
is  the  formation  of  inflammatory  masses  known  as  gummata,  with 
which  is  associated  diffuse  interstitial  chronic  inflammation ;  in 
most  cases  these  two  processes  are  combined,  the  gummata  result- 
ing from  the  greater  intensity  of  the  process  in  certain  parts. 

Gummata  are  tumours  of  syphilitic  origin  due  to  locaHsed  in- 
flammation. A  gumma  is  composed  of  small,  round,  densely  packed 
cells,  poorly  nourished  by  vessels  of  new  formiation,  which  them- 
selves soon  undergo  syphilitic  changes,  rendering  them  inadequate 
to  supply  sufficient  nourishment.  As  the  gumma  increases  in-  size, 
it  displaces  and  causes  atrophy  of  the  tissues ;  but  since  growth  is 
in  excess  of  destruction,  a  definite  tumour  or  syphiloma  is  formed, 
rarely  exceeding  the  size  of  a  walnut  unless  adjacent  gummata  have 
fused.  In  consequence  of  the  poorness  of  the  vascular  supply, 
gummata  are  very  prone  to  degenerate  and  soften,  and  unless  the 
process  be  arrested  and  absorption  favoured  by  treatment,  the 
overlying  skin  or  mucous  membrane  (in  the  case  of  gummata  so 
situated)  becomes  involved,  and  on  its  giving  way,  the  granular 
debris  mixed  with  pus  is  discharged  and  a  characteristic  sore  is 
produced.  Visceral  gummata  very  rarely  soften  and  break  down  ; 
they  may  undergo  more  or  less  complete  absorption,  their  situation 
being  marked  by  a  small  puckered  cicatrix.      Calcification  is  rare. 

To  the  naked  eye  a  gumma  superficially  resembles  a  patch  of 
caseous  tubercle,  but  the  pale  yellow,  degenerated  area  is  miore 
dense  and  elastic  unless  softening  has  occurred.  The  mass  is 
circumscribed  and  surrounded  by  a  more  or  less  dense,  grayish 
zone  of  chronic  inflammatory  tissue,  which  forms  an  imperfect  kind 
of  capsule.      In  tubercular   masses,   nodules  of   tubercle  are  seen 


176  MANUAL   OF   SURGERY  chap. 

surrounding  the  central  mass,  and  to  the  breaking  down  of  these 
the  increase  in  size  is  due.  Gummata  are  vascularised ;  tubercular 
patches  are  not. 

Gummata  progress  slowly  and  painlessly,  and  form  rounded 
elastic  tumours,  which  soften  and  involve  the  skin  as  degeneration 
advances.  In  the  early  stages  they  may  be  mistaken  for  definite 
new  growths,  especially  lipomata ;  but  their  situation  and  want  of 
lobulation,  together  with  other  evidences  of  syphilis  and  the  effects 
of  treatment,  will  usually  be  sufficient  to  avoid  error.  When  soften- 
ing has  occurred,  a  gumma  may  be  mistaken  for  a  subcutaneous, 
tubercular  abscess.  Broken-down  gummata  form  steeply-cut,  cir- 
cular, or  crescentic  ulcers,  with  steep  and  often  undermined  edges ; 
the  base  is  covered  with  a  tough  adherent  slough  like  wet  chamois 
leather.  When  the  slough  separates,  an  ulcer  secreting  thick 
tenacious  discharge  and  showing  no  tendency  to  improve  under 
ordinary  local  measures  results.  Healing  by  granulation  is  very 
rapid  under  iodide  treatment,  a  soft,  supple,  white,  non-contracting 
scar  being  left. 

The  tertiary  inflammation  may  give  birth  to  new  scar  tissue,  or 
may  ultimately  break  down,  soften,  and  ulcerate.  Tertiary  lesions 
have  a  strong  tendency  to  recur  again  and  again  in  the  same  tissue ; 
thus,  if  the  skin  be  affected,  a  relapse  of  the  symptoms  will  prob- 
ably affect  some  part  of  it.  The  skin  is  far  more  commonly 
affected  by  tertiary  lesions  than  is  any  other  tissue,  and  next  in 
order  of  frequency  the  bones,  nervous  system,  mucous  membranes, 
and  internal  organs.  It  is  in  the  nervous  system  and  the  internal 
organs  that  the  tertiary  phenomena  are  most  disastrous  in  their  effects. 

The  skin  and  mucous  membranes  may  be  the  seat  of  serpiginous 
ulcers  which  tend  to  recur  again  and  again ;  similar  inflammatory 
and  destructive  changes  may  occur  in  the  bones  leading  to  chronic 
periostitis  and  osteitis,  caries  or  necrosis,  and  in  the  viscera  to 
sclerotic  changes  which,  in  the  case  of  the  nervous  system,  may 
induce  paralysis  or  even  insanity.  The  joints,  synovial  bursae,  and 
tendon  sheaths  may  all  suffer.  As  regards  the  intestinal  tract  the 
rectum  is  most  commonly  affected,  and  stricture  usually  results  as 
the  new  scar  tissue  contracts.  Tertiary  syphilis  may  also  affect  the 
muscles,  but  rarely  does  so,  except  in  the  case  of  the  tongue. 

SYPHILITIC    AFFECTIONS    OF    THE    SKIN 

Syphilitic  eruptions,  known  as  syphilides  or  syphilodermata, 
have  their  non-syphilitic  prototypes,  but  their  specific  origin  confers 


IX  SYPHILITIC   AFFECTIONS   OF   THE   SKIN         177 

upon  them  certain  peculiarities  of  diagnostic  import.  Such 
peculiarities  vary  with  the  situation  of  the  eruption,  and  accord- 
ing to  whether  it  be  kept  dry  and  unirritated,  or  moist  and  warm. 

Special  features  of  the  syphilides. — Syphilitic  eruptions  pre- 
sent the  following  diagnostic  features  : — 

(i)  They  are,  to  a  large  extent,  composed  of  dense  collections 
of  cells,  and  are  consequently  solid  and  firm  to  the  touch,  and  do 
not  disappear  on  pressure ;  the  macular  syphilide  is,  however, 
exceptional  in  these  respects  (p.  178). 

(2)  Their  course  is  indolent,  and  they  tend  to  recur,  perhaps 
again  and  again,  for  months — sometimes  for  years. 

(3)  They  tend  to  disappear  spontaneously  after  a  time,  and 
rapidly  do  so  under  the  influence  of  mercury  in  the  early  stages  of 
the  disease  and  of  the  iodides  in  the  tertiary. 

(4)  The  individual  spots  have  a  rounded  outline,  and  the 
earlier  maculo-papular  or  papulo-nodular  lesions  are  irregularly 
distributed.  They  undergo  centrifugal  extension,  so  that  they  tend 
to  become  ringed,  and  by  confluence  may  produce  varied  figured' 
patterns,  or  become  crescentic.  The  later  lesions  tend  to  be 
grouped  by  the  formation  of  fresh  lesions  around  the  sites  of  the 
older  disappearing  ones,  and  in  this  way  the  eruption  may  creep, 
in  the  form  of  segments  of  circles,  across  a  region  (serpiginous 
spread). 

(5)  The  eruptions  are  copious,  widely  distributed,  symmetrical, 
and  superficial  during  the  early  secondary  stage,  but  with  remote- 
ness of  the  date  of  infection  they  become  less  copious,  more 
localised,  asymmetrical,  and  tend  to  affect  the  deeper  layers  of  the 
skin,  the  subcutaneous  structures,  and  the  viscera. 

(6)  The  earlier  lesions  are  frequently  multiform  or  polymorphic 
in  character.  This  polym.orphism  may  be  due  to  the  simultaneous 
presence  of  various  types  of  eruption,  e.g.  the  macular,  papules  of 
varying  size,  vesicles,  pustules,  etc.,  or  to  the  various  stages  which 
such  eruptions  undergo,  or  to  their  modification  in  special  regions, 
e.g.  a  papular  eruption  tends  to  become  crusted  about  the  forehead 
and  scalp,  to  form  condylomata  about  the  anus,  vulva,  or  other 
warm  and  moist  regions,  and  to  form  mucous  patches  in  the 
mouth. 

(7)  The  lesions  are  of  a  copper}^-red  or  raw-ham  colour  from  the 
escape  of  the  red  blood  cells,  and  when  they  die  away,  leave  marked 
staining. 

(8)  The  eruptions  do  not  as  a  rule  cause  pain,  itching,  irrita- 
tion, or  any  subjective  sensation. 

VOL.  I  N 


1 78  MANUAL  OF   SURGERY  chap. 

(9)  The  different  syphilides  show  a  special  predilection  for 
certain  sites,  thus  the  macular  form  especially  affects  the  abdomen, 
the  early  papular  eruption  selects  the  flexor  rather  than  the 
extensor  aspects  of  the  limbs,  and  the  mucous  membranes  of  the 
mouth,  throat,  and  larynx  are  ver)'  prone  to  be  affected. 

Varieties. — SyphiHtic  eruptions  may  be  macular,  papular,  vesi- 
cular, pustular,  bullous,  pigmentar}',  and  nodular  or  gummatous,  but 
they  are  all  due  to  a  process  of  inflammation  of  greater  or  less 
intensity,  involving  the  superficial  papillary  layer  of  the  skin,  or 
extending  more  deeply,  and  hence  they  tend  to  merge  the  one  into 
the  other.  There  is  round-celled  infiltration  in  the  immediate 
neighbourhood  of  the  blood-vessels,  the  round  cells  being  escaped 
leucocytes  with  which  are  mixed  a  few  red  cells  to  which  the 
characteristic  pigmentation  is  due.  If  the  vascular  hyperaemia  is 
circumscribed,  and  the  cellular  infiltration  is  slight,  the  macular 
syphilide  results  ;  when  the  infiltration  of  the  papillary  body  is 
marked,  papules  of  varying  size  occur,  and  such  may,  from  the  in- 
tensity of  the  process,  become  vesicular,  bullous,  or  pustular.  In 
the  most  marked  cases  of  infiltration  in  which  the  process  extends 
deeply,  perhaps  involving  the  subcutaneous  connective  tissue,  the 
nodular  or  gummatous  syphilide  results,  and  by  the  disintegration  of 
the  inflammatory  tissue  ulceration  follows,  and  may  assume  serpi- 
ginous characters  owing  to  central  healing  with  fresh  invasion  at 
the  periphery.  When  absorption  occurs,  it  is  often  many  months 
before  all  traces  of  the  eruption  disappear,  the  pigmentation  being 
very  often  long  persistent. 

The  macular  or  roseolar  syphilide. — This,  the  earliest 
and  m.ost  constant  of  the  eruptions,  usually  makes  its  appearance 
about  six  weeks  after  that  of  the  initial  lesion,  but  it  not  in- 
frequently escapes  notice.  The  eruption  may  be  profuse  or  scanty, 
and  chiefly  affects  the  anterior  aspect  of  the  trunk,  especially  the 
abdomen  ;  it  gradually  attains  a  maximum  in  about  a  fortnight, 
and  within  another  week  begins  to  fade,  but  relapses  are  common. 
The  maculae  vary  in  size,  being  usually  that  of  a  split  pea,  but 
sometimes  as  large  as  a  shilling.  They  are  at  first  of  a  pale  rose- 
red  colour  and  fade  on  pressure,  but  later  on  the  colour  is  more 
livid,  and  as  the  eruption  fades,  is  replaced  by  coppery  discolora- 
tion. There  may  be,  but  rarely  is,  slight  desquamation.  The 
macular  and  papular  syphilides  are  usually  concurrent,  and  with  the 
appearance  of  the  former,  there  is  frequently  erythema  of  the 
fauces,  and  perhaps  of  the  laryngeal  mucous  membrane. 

The   papular   and   papulo  -  squamous   syphilide. — The 


IX  SYPHILITIC   AFFECTIONS   OF  THE  SKIN        179 

papules  arc  due  to  cellular  infiltration  of  the  papillary  body,  and 
present  themselves  under  a  great  variety  of  forms.  The  individual 
lesions  are  solid,  strictly  circumscribed,  raised  above  the  surface, 
and  of  a  raw-ham  or  coppery  colour ;  the  epithelium  usually  pro- 
liferates and  separates  from  the  papule,  its  remains  showing  as  a 
silvery  collarette.  The  papules  may  be  large  or  small,  discrete  or 
fused,  and  are  often  arranged  in  circular  or  crescentic  groups.  It  is 
important  to  note  that  the  character  of  the  eruption  is  modified  by 
its  situation  ;  thus  in  the  palm  and  sole  the  proliferation  of  the 
epithelium  is  a  marked  feature,  and  the  papules  become  hard  and 
horny  on  the  surface  (papulo-squamous  syphilide),  and  are  not  in- 
frequently painfully  fissured ;  papules  in  warm  and  moist  situations, 
e.g.  round  the  vulva  or  in  the  mouth  and  throat,  form  condy- 
lomata or  mucous  tubercles  which  will  be  referred  to  later  on. 

The  small  op  miliary  papule  occurs  in  corymbose  clusters 
seated  round  the  hair  or  sebaceous  follicles,  and  varies  in  size  up  to 
that  of  a  lentil ;  the  papules  are  distinctly  shotty,  and  are  at  first 
pinkish  in  colour,  but  soon  assume  the  characteristic  coppery  tint 
and  leave  slight  staining  as  they  die  away.  The  eruption  may 
appear  in  successive  crops,  chiefly  affecting  the  trunk  and  hmbs  ; 
it  may  last  for  six  weeks  or  as  many  months.  Sometimes  the 
miliary  papule  suppurates,  and  thus  passes  into  the  acneiform 
pustular  eruption  (see  p.  181). 

The  lapge  papular  or  lenticular  syphilide  is  very  common, 
and  occurs  coincidently  with,  or  very  soon  after,  the  macular 
eruption  ;  it  is,  however,  very  liable  to  relapse,  and  consequently 
may  be  present  years  after  infection.  The  papules,  which  may  be 
as  large  as  a  sixpence,  are  rounded  and  flattened ;  they  make  their 
appearance  in  successive  crops  which  gradually  fade  away,  although 
evidence  of  their  occurrence  often  persists  in  the  form  of  coppery 
staining  for  many  months.  This  form  of  eruption  may  be  uni- 
versally distributed,  but  shows  a  special  predilection  for  the  nape 
of  the  neck,  the  forehead  along  the  line  of  the  hair  (corona  veneris), 
the  mucous  membrane  of  the  mouth,  the  flexor  aspects  of  the  limbs, 
and  for  the  palms  and  soles ;  the  last  two  situations  are  often 
favoured  by  late  relapses  of  the  eruption.  The  epithelium  fre- 
quently desquamates  and  covers  the  surface  of  the  papule  with 
silvery  scales  (squamous  or  scaly  syphilide),  so-called  syphilitic 
psoriasis. 

Moist  papules,  mucous  patches,  or  condylomata  (Fig.  35,  p.  180) 
result  when  the  papular  eruption  affects  warm  and  moist  regions. 
They  are  consequently  especially  met  w^th  round  the  anus,  between 


i8o 


MANUAL   OF   SURGERY 


CHAP. 


the  folds  of  the  buttocks,  round  the  vulva,  in  the  axillre,  in  the  sulcus 
beneath  the  breasts,  round  the  mouth,  especially  at  the  angles,  and 
between  the  toes.  The  papules  are  broad,  flattened,  soft,  and 
often  confluent ;  the  sodden  surface  epithelium  desquamates,  and 
the  mucous  plaques  secrete  a  thick,  tenacious,  offensive,  and  highly- 
contagious  secretion.  This  secretion  is  auto-inoculable,  and  hence 
mucous  tubercles  give  birth  to  others  on  parts  with  which  they 
may  be  brought  in  contact,  e.g.  the  inner  side  of  the  thigh  and 
labium,  and  the  folds  of  the  nates.  If  the  individual  plaques  fuse, 
a  considerable  area  may  be  afl'ected,  and  owing  to  irritative  over- 
growth of  the  papilla  the  mass  increases  in   thickness,  and  has  a 


Fig.  35. — Syphilitic  ulcers  and  condylomata  (Jullien). 

fungous  appearance.  Sometimes,  e.g.  about  the  angles  of  the 
mouth,  mucous  patches  become  fissured,  or  they  may  ulcerate,  and 
especially  tend  to  do  so  when  they  are  situated  between  the  toes 
(rhagades).  The  resulting  ulcers  are  very  foul,  but  rapidly  heal 
under  mercurial  treatment.  Mucous  tubercles  in  the  mouth  and 
throat  lead  to  characteristic  ulceration,  chiefly  affecting  the  tonsils, 
palate,  fauces,  sides  of  the  tongue,  and  buccal,  mucous  membrane 
(see  p.  185).  When  it  occurs  on  the  palms  and  soles  the 
papular  eruption  is  modified  by  the  thickness  of  the  epidermis, 
and  appears  as  the  so-called  palmar  psoriasis.  The  hypersemic 
areas  are  covered  with  proliferated  and  desquamating  epithelu^m, 
which,  separating  at  the  margins,  tends  to  curl  up,  but  rem\iins 
adherent    at     the    centre     of    the    patch ;    painful     fissures     and 


IX  SYPHILITIC   AFFECTIONS   OF  THE   SKIN         i8i 

cracks  are  common,  and  especially  occur  along  the  normal  lines 
of  llexure  of  the  skin.  Palmar  psoriasis  tends  to  spread  peri- 
pherally, but  may  heal  in  the  centre ;  it  is  often  asymmetrical, 
is  very  persistent  and  liable  to  relapse,  and  may  be  met  with 
years  after  infection.  Its  presence  is  of  great  diagnostic  value. 
In  some  cases  the  epithelium  does  not  desquamate,  but,  continuing 
to  proliferate,  forms  a  dense,  hard,  and  horny  patch. 

The  vesicular  syphilide. — This  form  is  extremely  rare,  and 
usually  occurs  as  the  eczematous  variety,  but  varicelliform  and 
herpetiform  syphilides  are  described.  The  eczematous  syphilide 
occurs  in  successive  patches  or  groups  of  very  small  vesicles  situated 
on  coppery  areas,  which  are  formed  by  the  coalescence  of  the 
coppery  rings  which  surround  each  individual  vesicle.  The  vesicles 
contain  clear,  but  sometimes  cloudy,  fluid  which  dries  up  and 
leaves  an  adherent  scale  which,  on  separating,  leaves  coppery  stain- 
ing. The  vesicular  eruption  is  usually  an  early  manifestation,  and 
may  become  pustular. 

The  pustular  syphilide. — The  development  of  pustules 
usually  occurs  as  a  late  manifestation  of  the  disease,  and  is  yery 
rarely  met  with  unless  the  patient's  health  be  markedly  deteriorated. 
The  pustular  stands  in  an  intermediate  position  between  the 
vesicular  and  bullous  eruptions.  The  pustules  vary  considerably 
in  size,  but  when  they  occur  early  they  are  usually  small ;  they 
may  be  localised  or  diffuse,  and  are  sometimes  grouped ;  they 
vary  in  shape  and  in  their  distribution,  and  each  is  surrounded  by 
a  coppery  ring.  When  the  pustules  burst  they  become  covered 
with  a  crust,  beneath  which  ulceration  extends.  The  various  forms 
of  pustular  eruption  are  named  according  to  the  non-syphilitic 
eruption  which  they  mimic.  Thus  they  may  be  acneiform,  varicelli- 
form, varioliform,  ecthymatous,  etc. 

The  acneiform  syphilide,  as  already  stated,  is  a  suppurating 
form  of  the  small  papular  eruption,  with  which  it  is  often  asso- 
ciated (see  p.  179).  This  eruption  usually  occurs  early,  and  is  not 
infrequently  universally  distributed,  although  showing  a  preference 
for  the  face  and  shoulders.  The  pustules  are  small,  and  are 
seated  on  coppery  papules ;  as  the  pus  dries,  a  thin  scale  is  left 
which  falls  and  leaves  a  small  scar. 

The  impetig-inous  and  ecthymatous  syphilides  occur  as  large 
pustules  seated  on  coppery  papules.  The  lesions  soon  become 
covered  with  crusts,  beneath  which  ulceration  may  extend  widely. 
The  impetiginous  form  is  usually  localised  to  the  face,  scalp,  and 
genitals,  but  respects  the  limbs,  whereas  the  ecthymatous,  although 


l82 


MANUAL  OF   SURGERY 


CHAP. 


it  may  occur  anywhere,  shows  a  predilection  for  the  shoulders, 
back,  and  limbs.  The  ecthymatous  syphilide  may  occur  early  or 
late,  the  early  lesions  being  usually  smaller  and  more  superficial 
than  are  the  late,  which  occur  coincidently  with  the  tertiary  lesions  of 
the  bones  and  viscera ;  the  late  form  is  marked,  moreover,  by  the 
great  tendency  to  the  formation  of  adherent  crusts  on  the  surface  of 

ulceration  (pustulo  -  crust- 
aeeous  syphilide — rupia. 
Fig.  7,6).  Rupia  is  dia- 
gnostic of  acquired  syphilis; 
it  never  occurs  in  the  in- 
herited disease,  and  only 
attacks  patients  in  vitiated 
health,  which  may  be  further 
impaired  with  the  advent  of 
the  eruption.  As  the  ulcera- 
tion extends  in  area,  so  each 
succeeding  lamina  of  crust 
is  larger  than  the  last,  and 
hence  the  scab  assumes 
the  characteristic,  conical,  or 
limpet-shell  shape ;  if  this 
be  removed,  a  deep  ulcer, 
surrounded  by  a  red  areola, 
is  disclosed,  which  will,  un- 
less constitutional  treatment 
be  adopted,  gradually  spread, 
and  may  assume  serpiginous 
characters.  When  the  ulcer 
heals  a  deeply  stained  scar 
results,  but  in  the  course 
of  time  this  becomes 
white,  thin,  shiny,  and 
supple,     and     it     may    for 


Fig.  36. — Rupia  syphilitica  (JuUien). 


some  time  be  surrounded  by  a  pigmented  ring. 

All  the  pustular  syphilides  are  Hable  to  persist  for  a  long  time 
and  to  relapse ;  they  must  in  all  cases  be  regarded  as  serious 
manifestations,  indicating  as  they  do,  either  a  naturally  weak  consti- 
tution, or  one  which  has  been  undermined  by  privation,  debauchery, 
or  some  other  cause  ;  they  are  also  likely  to  occur  in  malignant 
forms  of  syphilis  in  which  the  patient  has  proved  very  refractory  to 
mercurial  treatment. 


IX 


SYPHILITIC   AFFECTIONS   OF  THE   SKIN 


183 


The  bullous  syphilide  is  practically  identical  with  the  large 
pustular  form,  and  gives  rise  to  eruptions  like  ecthyma  or  rupia. 
Sy[)hilitic  pemphigus  (Fig.  37)  has  occasionally  been  noted  as 
occurring  in  the  acquired  disease,  but  it  is  essentially  a  manifes- 
tation of  the  hereditary.  The  bullae  form  on  the  palms  and 
soles. 

The  pigmentary,  leucodermia-like  or  dappled  syphilide. 
— This  purely  pigmentary  change  is  a  secondary  manifestation,  and 
occurs  almost  exclusively  in  women,  affecting  the  sides  of  the  neck, 
although  it  is  occasionally  seen  elsewhere.  The  eruption  consists 
of  discrete,  rounded,  cafc-au-lait  coloured  stains,  which  may  be  very 


Fig.  37. — Pemphigus  and  circular  ulcerations  in  an  infant  with  congenital  syphilis  (Follin). 

faint,  so  that  they  can  only  be  seen  in  certain  lights ;  they  are  not 
raised  above  the  surface,  and  do  not  desquamate.  The  spots  may 
attain  the  size  of  a  sixpence,  and  by  confluence  may  give  rise  to 
a  peculiar  lace-work  pattern  enclosing  areas  of  unaltered  skin  which 
looks  by  contrast  whiter  than  normal.  The  affection  is  very  per- 
sistent, and  resists  anti-specific  treatment ;  it  is  not  quite  certain 
that  the  eruption  should  be  regarded  as  peculiar  to  syphilis,  and 
that  it  may  not  occur  in  persons  of  depraved  health  from  other 
causes.  The  pigmentary  syphilide  is  not  to  be  confounded  with 
the  staining  which  remains  when  other  eruptions  have  died  away  ; 
it  is  also  to  be  distinguished  from  tinea  versicolor,  in  which  disease 
the  pigment  is  on  and  not  in  the  skin. 

The  nodular  or  gummatous  syphilide. — This  lesion  be- 
longs essentially  to  the  tertiary  stage  of  the  disease,  but  may  occur 


1 84  MANUAL  OF   SURGERY  chap. 

at  the  end  of  the  second  year ;  it  is  especially  met  with  in  cachetic 
patients,  whose  health  is  seriously  broken  down.  The  nodules  may 
be  as  large  as  a  pea,  bean,  or  walnut,  and  may  implicate  the  deeper 
parts  and  the  subcutaneous  tissue  (subcutaneous  gummata).  They 
are  rounded  or  oval  in  shape,  solid  and  dense  to  the  touch,  and 
coppery  or  brownish  in  colour.  If  the  eruption  occurs  early  in  the 
evolution  of  the  disease  it  is  liable  to  be  widespread  and  symmetrically 
distributed,  but  during  the  later  years  it  is  more  scattered,  less 
likely  to  be  symmetrical,  and  by  confluence  large  patches  may  be 
formed.  The  nodules  have  a  special  tendency  to  appear  in  clusters, 
and  as  the  old  ones  die  away  others  appear  at  some  part  of  the  peri- 
phery, and  so  circles,  or  segments  of  circles,  sometimes  reniform,  may 
be  formed.  In  this  manner  the  eruption  will  wander  across  a  particular 
region,  as  in  some  cases  of  lupus  {serpiginous  spread).  Relapses  are 
common,  successive  crops  of  nodules  appearing  from  time  to  time, 
and  although  no  part  is  exempt,  yet  they  especially  favour  the  face, 
forehead,  neck,  and  arms.  When  the  nodular  syphilide  has  reached 
a  maximum,  it  may  die  away  or  ulcerate,  and  thus  two  forms,  the 
ulcerating  and  the  non-ulcerating,  are  usually  described.  In  the  non- 
ulcerating  form  the  nodules  gradually  undergo  absorption,  and  the 
subcutaneous  tissue  may  participate,  so  that  a  scar  is  left  which 
gradually  increases  in  extent  if  the  eruption,  by  spreading  at  its 
periphery,  assumes  serpiginous  characters.  Sometimes  the  nodules 
project  considerably  beyond  the  surface,  and  may  be  crusted  or 
covered  with  desquamating  epithelium.  The  nodular  syphilide  is 
especially  prone  to  ulcerate  if  the  health  of  the  patient  is  vitiated ; 
the  ulceration  sometimes  extends  widely  and  deeply,  and  with  con- 
siderable rapidity ;  at  others  it  progresses  more  slowly  and  tends  to 
spread  in  superficial  area  rather  than  in  depth,  and  to  assume 
serpiginous  characters.  The  superficial  ulcers  are  covered  with  a 
dirty  brown  crust ;  they  assume  an  oval  or  crescentic  shape,  healing 
in  the  centre  and  spreading  at  the  periphery,  so  that  the  lesion 
may  travel  a  long  distance  from  the  point  of  its  initial  manifesta- 
tion. When  healing  occurs  the  cicatrix  is  livid,  and  may  remain  so 
for  a  very  long  time.  When  the  process  of  ulceration  extends 
deeply  a  characteristic  gummatous  ulcer  results,  and  in  certain 
parts,  e.g.  the  nose,  considerable  destruction  may  ensue.  These 
gummata  are  rarely  numerous,  and  are  especially  met  with  about 
the  face,  nose,  scalp,  and  in  the  neighbourhood  of  the  knee  and 
elbow,  but  they  may  occur  anywhere. 


IX  SYPHILITIC   AFI'ECTIONS  OF  THE  HAIR 


SYPHILITIC    AFFECTIONS    OF    THE    MUCOUS    MEMBRANES 

With  the  appearance  of  the  macular  syphiHde  there  is  general 
erythema  of  the  fauces,  palate,  and  tonsils,  and  sometimes  of  the 
laryngeal  mucous  membrane,  accompanied  by  some  slight  discomfort 
and  dryness  of  the  throat  with  hoarseness,  but  no  actual  pain.  During 
the  period  of  evolution  of  the  papular  eruption  this  involves  the 
mucous  membrane  of  the  fauces,  tonsils,  sides  of  the  tongue,  floor 
of  the  mouth,  and  buccal  aspect  of  the  lips  and  cheeks,  but  the 
lesions  become  altered  in  appearance.  On  the  mucous  surfaces 
the  lesions  appear  as  small,  reniform,  or  crescentic  superficial  ulcers, 
which  have  a  dirty  ashy-gray  base,  and  a  dead  white  margin  of 
sodden  epithelium  ;  these  ulcers  are  usually  symmetrical,  arid  do 
not  show  any  tendency  to  spread  either  in 
superficial  area  or  depth,  nor  are  they 
usually  very  painful,  although  they  cause 
some  stiffness  and  soreness  of  the  throat. 
The  patient  may  sometimes  be  uncon- 
scious of  their  presence ;  the  secretion 
from  these  ulcers  renders  the  saliva  highly 
contagious.  Sometimes  there  is  consider- 
able overgrowth,  and  the  patches  project  [^ 
more  or  less  beyond  the  surface  (mucous 
tubercles,  condylomata) ;  this  is  very  likely 
to  happen  at  the  sides  of  the  tongue  and 
angles  of  the  mouth.  Similar  patches 
are  also  coincidently  present  at  the  vulva 
and  round  the  anus  (Fig.  35,  p.  180) ;  but 
whether  they  occur  in  any  other  part  of 
the  intestinal  tract  is  unknown. 

Tertiary  ulceration  is  commonly  met 
with  about  the   throat,  tongue  (Fig.  38), 
lips,  cheeks,  and  larynx,  and  (especially  in  women)  the  lower  end  of 
the  rectum  and  the  anus  may  be  affected. 


Fig.  38.  —  Extensive  Assuring  of 
the  tongue  following  syphilitic 
ulceration  (Follin,  after  Clarke). 


SYPHILITIC    AFFECTIONS    OF    THE    HAIR SYPHILITIC    ALOPECIA 

The  hair  may  be  affected  in  consequence  of  general  want  of 
nutrition  and  cachexia,  or  as  the  result  of  some  syphilide  of  the 
scalp.  The  hair  loses  its  lustre,  becomes  brittle,  dry,  and  falls. 
The  loss  of  hair  may  be  patchy  and  scanty,  or  m.ay  be  general  and 
profuse ;  it  generally  occurs  during  the  first  year  of  the  disease,  but 


i86 


MANUAL   OF   SURGERY 


CHAP. 


sometimes  at  later  periods ;  under  treatment,  and  especially  with 
general  improvement  in  the  patient's  health,  the  hair  quickly  grows 
again,  but  if  its  loss  is  due  to  ulceration  of  the  scalp,  baldness 
will  be  permanent. 


SYPHILITIC    AFFECTIONS    OF    THE    NAILS ONYCHIA PERIONYCHIA 

These  affections   are   due  to  want   of  nutrition,   or  to  inflam- 
__  matory      or      ulcerative 

lesions  affecting  the 
matrix.  In  the  case  of 
onychia  the  nails  (many 
of  which  may  suffer) 
become  longitudinally 
furrowed,  brittle,  jagged, 
and  are  eventually  cast ; 
sometimes  there  is  a 
deep  groove  across  the 
nail  at  the  base  of  the 
semilunar  furrow.  Peri- 
onychia  or  inflammation 
of  the  matrix  of  the  nail 
is  associated  with  the 
appearance  of  some  form 
of  syphilide ;  the  nail  is 
deprived  of  its  nutrition 
and  may  be  shed,  but 
usually  grows  again  with- 
out marked  deformity. 
Sometimes  perionychia 
is  associated  with  con- 
siderable ulceration,  dis- 
charge, and  pain.  These  lesions  usually  occur  during  the  first  year, 
but  like  those  affecting  the  hair,  may  do  so  at  a  later  period. 


Fig.  39. — Syphilitic  dactylitis  and  onychia, 
(Follin,   after  Blum.) 


SYPHILITIC    AFFECTIONS    OF    THE    LYMPHx\TIC    GLANDS 

About  a  week  or  ten  days  after  the  appearance  cf  the  primary 
chancre,  the  lymphatic  glands  in  the  neighbourhood  undergo 
indolent  enlargement,  unaccompanied  by  pain  or  tenderness,  or  by 
any  signs  of  acute  inflammation  ;  they  do  not  suppurate,  and  after 
remaining  for  a  time  in  statu  ^uo,  gradually  resume  their  normal 


IX         SYnilLITIC   AFFECTIONS   OF  THE  JOINTS      187 

size  in  from  four  to  six  months.  It  not  infrequently  happens  that 
at  the  period  of  greatest  intensity  of  the  early  syphilide,  there 
is  a  general  enlargement  and  tenderness  of  the  lymphatic  glands 
throughout  the  body,  but  unlike  that  occurring  in  association  with 
the  primary  sore  this  enlargement  is  transitory  in  nature,  and  is 
unaccompanied  by  induration.  When  the  throat  is  affected  there 
is  often  subacute  sympathetic  inflammation  of  the  submaxillary 
lymphatic  glands,  and  occasionally  of  those  beneath  the  sterno- 
mastoid.  It  is  to  be  noted  that  the  tertiary  eruptions  and  ulcera- 
tions are  unaccompanied  by  glandular  involvement. 

SYPHILITIC    AFFECTIONS    OF    THE    MUSCLES    AND    BURS^ 

Rheumatoid  pains  are  not  uncommon  in  the  early  secondary 
stage,  but  gummatous  lesions  are  rare,  the  muscular  substance  of 
the  tongue  being  their  most  common  site  (see  Diseases  of  the 
Tongue,  vol.  iii.),  in  which  situation  care  must  be  taken  to  diagnose 
the  affection  from  cancer. 

The  bursce,  especially  that  in  front  of  the  patella,  may  be  the 
seat  of  gummatous  inflammation,  which  may  originate  in  the  con- 
nective tissue  surrounding  it. 


SYPHILITIC    AFFECTIONS    OF    THE    JOINTS 

In  the  early  secondary  stage  the  patient  occasionally  complains 
of  rheumatoid  pains  in  the  joints.  In  rare  instances  one  of  the 
larger  joints,  usually  the  knee,  is  the  seat  of  transient  acute  synovitis 
and  is  filled  with  fluid;  there  is,  however,  as  in  the  case  of  the 
earlier  periostitis,  no  tendency  to  suppuration,  and  the  condition 
quickly  subsides  under  mercurial  treatment,  and  leaves  no  traces 
behind  it.  During  the  tertiary  period  peri-synovial  gummata  may 
affect  the  fibrous  tissues  round  the  knee,  and  less  frequently  round 
the  elbow  joints  ;  the  gummata  may  burst  on  the  surface,  but  rarely 
do  so  into  the  joint,  although  there  is  not  uncommonly  some 
associated  synovitis.  This  manifestation  is  much  more  likely  to 
occur  in  women  than  in  men,  runs  a  chronic  course,  and  is  very 
liable  to  relapse  even  after  apparent  complete  cure. 

Chronie  gummatous  synovitis  may  occur  during  the  tertiary 
period,  but  is  very  rare.  It  chiefly  affects  the  knee,  and  very 
closely  simulates  white  swelling  (the  syphilitic  pseudo-w^hite  swelling 
of  Richet).  The  condition  runs  a  very  chronic  course  and  causes 
the  patient  but  very  little  inconvenience.     It  is  very  amenable  to 


iS8 


MANUAL   OF   SURGERY 


CHAP. 


anti-syphilitic  remedies,  but  if  these  be  not  administered,  destructive 
arthritis  may  ensue,  or  a  certain  amount  of  fibrous  ankylosis  may  result. 
Lastly,  the  joints  may  be  secondarily  involved  by  articular 
caries  due  to  gummatous  infiltration  of  the  cancellous  tissue  of  the 
bones  entering  into  their  formation  (see  also  chap.  vi.  vol.  iii.). 


SYPHILITIC    AFFECTIONS    OF    THE    BOXES 

With  the  onset  of  the  exanthematous  stage,  pains  in  the  bones 
of   greater   or   less   severity   are   not   uncommonly   experienced   in 

association  with  neuralgia  of  the 
muscles  and  joints  (syphilitic  rheu- 
matism). Periostitis,  slight  and  tran- 
sient in  nature,  and  having  no  tendency 
to  suppurate,  or  very  little  to  lead  to 
the  formation  of  new  bone,  is  also 
common.  In  the  late  secondary  and 
tertiary  stages,  chronic  periostitis  with 
V^.^lfe^<^^A^^^£^U  the  formation  of  nodes,  sclerosing 
"'        '"  osteitis,    and     necrosis     are     common 

manifestations  of  the  disease.  Although 
any  bone  may  be  affected,  those  super- 
ficially placed  are  specially  prone  to 
suffer;  thus  the  calvaria,  palate,  bones 
of  the  nasal  fossae  and  the  tibiae  are 
Fig.  4o.— Syphilitic  caries  and  necrosis  frequently  affectcd,  and  in  the  first 
dV  u^™  ^  Fo'iiSi.t"^^    ^'^^"'^^    situation    the    consequences    may    be 

grave,  owing  to  involvement  of  the 
inner  table  and  consecutive  disease  of  the  meninges  and  brain. 
Syphilitic  dactylitis  closely  resembles  the  tubercular  variety  (see 
Fig.  39.  P-  iS6). 

Syphilitic  inflammation  of  the  periosteum  or  bones  may  run  a 
ver}'  chronic  course,  being  chiefly  characterised  by  the  formation  of 
new  osseous  tissue,  but  sometimes  the  course  is  more  acute,  and  the 
gummatous  tissue  softens,  breaks  down,  and  abscess  results.  The 
special  aflfections  of  the  bone  met  with  in  hereditary  sj^hihs  will  be 
subsequently  referred  to  (see  p.  203). 


SYPHILITIC    AFFECTIONS    OF    THE    BLOOD-VESSELS 

The  intima  of  the  arteries  is  especially  affected.      When  arterial 
disease  occurs,  it  is  in  most  cases  early  in  the  secondary  stage,  but 


IX  SYPHILITIC   AFFECTIONS   OF   THE   EYES  189 

such  changes  may,  Hke  the  other  lesions  of  this  period,  quite  clear 
up.  During  the  late  secondary  or  tertiary  stage,  atheroma  of  the 
larger  vessels  and  endarteritis  of  the  smaller  (especially  those  of 
the  brain)  may  occur.  Syphilitic  endarteritis  is  characterised  by 
proliferation  of  the  intima  at  one  side  of  the  arter)',  which  con- 
sequently bulges  into  the  lumen  and  narrows  it.  Gradual  infiltra- 
tion of  the  coats  renders  them  thick  and  rigid.  As  a  result  of 
such  changes,  aneurism,  thrombosis,  or  gradual  obliteration  of  the 
vessels  mav  occur,  and  in  the  case  of  the  brain  and  cord  serious 
ner\-ous  lesions,  such  as  hemiplegia  and  paraplegia,  may  result  from 
the  consequent  interference  with  the  nutrition  of  the  ner\"0us 
elements. 


SYPHILITIC    AFFECTION'S    OF    THE    NERVOUS    SYSTEM 

During  the  last  quarter  of  a  century  many  observers  have  shown 
that  the  first  two  years  after  infection  exhibit  an  extraordinary-  pre- 
dominance, as  far  as  the  development  of  nervous  symptoms  is  con- 
cerned, over  any  similar  period  during  the  whole  course  of  the 
disease.  They  prove  that  nearly  one-half  of  all  the  ner\-ous 
aftections  met  with  in  syphilis  appear  during  the  first  two  years, 
Such  lesions  may,  however,  appear  very  many  years  after  infection, 
and  so  great  is  the  connection  between  antecedent  syphilis  and 
nervous  diseases  that,  in  all  cases  of  the  latter,  a  history  of  the 
former  should  be  diligently  sought  for.  Nervous  lesions  may  be 
occasioned  by  disease  of  the  basal  arteries,  by  sclerosis  or 
gmnmatous  deposits  in  the  meninges,  by  gummatous  deposits, 
thickening  or  sclerosis  of  indi\-idual  nerves  (notably  the  third  or 
oculo-motor),  which  lead  to  local  paralysis,  and  lastly,  by  the 
occurrence  of  meninso-mvelitis  or  s^mmata  in  the  nervous  tissue, 
which  probably  originate  in  the  peri-arterial  structures.  Tabes 
dorsalis  and  general  paralysis  of  the  insane  may  be  specially 
mentioned  in  connection  with  this  subject. 


SYPHILITIC    AFFECTIONS    OF    THE    EYES 

Iritis  is  not  uncommon  during  the  secondar}'  stage  of  syphilis, 
and  occurs  coincidently  with  the  skin  lesions.  Both  eyes  are 
frequently  involved.  The  inflammation  is  chiefly  characterised  by 
a  marked  tendency  to  plastic  infiltration ;  small  beads  of  hniph  are 
seen  on  the  posterior  surface  of  the  cornea,  and  similar  nodules 
may  be   present   on   the    iris.      The   usual   symptoms   of  iritis  are 


190  MANUAL  OF   SURGERY  chap. 

present,  but  the  pain  and  photophobia  are  notably  less  than  in  non- 
specific cases.  Interstitial  keratitis  has  been  occasionally  met 
with  in  the  acquired  disease.  In  the  late  secondary,  latent,  or 
tertiary  periods  inflammation  may  occur  in  the  deeper  structures. 
Disseminated  or  diffuse  choroiditis,  associated  with  retinitis,  is  the 
most  common ;  the  disease  is  very  insidious  and  persistent.  Papil- 
litis and  interstitial  retro -bulbar  optic  neuritis  may  also  be  met 
with. 

Ocular  paralysis  from  involvement  of  the  third  nerve  or  its 
nuclei,  or  in  association  with  meningitis,  is  not  rare  in  the  late 
secondary  or  tertiary  stages ;  the  muscles  affected  vary,  the 
pupil  may  be  dilated,  and  the  levator  palpebree  superioris  paralysed ; 
drooping  of  the  upper  lid  is  very  suggestive  of  syphilis. 

SYPHILITIC    AFFECTIONS    OF    THE    VISCERA 

Lesions  of  the  viscera  are  usually  late  manifestations.  The 
lesion  consists  in  diffuse  or  localised  interstitial  inflammation.  In 
the  localised  form  new  growths  (gummata  or  syphilomata)  make 
their  appearance  as  they  do  in  other  tissue,  but  when  affecting  the 
internal  viscera  they  do  not  show  the  same  tendency  to  soften 
and  break  down,  but  rather  to  undergo  fibrotic  changes.  Of  the 
viscera,  the  liver  and  body  of  the  testis  are  most  frequently  affected  ; 
but  in  the  latter  situation,  softening  with  gradual  involvement  of  the 
superficial  structures  and  subsequent  formation  of  a  gummatous 
ulcer  are  common.  When  the  abdominal  viscera  are  the  seat  of 
syphilitic  inflammation,  the  fibrous  capsule  and  investing  peritoneum 
are  thickened  from  the  same  cause.  The  lungs  are  sometimes  in- 
durated as  in  chronic  phthisis,  and  cavities  may  result  from  break- 
ing down  of  the  gummata;  the  change  is  usually  limited  to  one 
lobe.  The  larynx  is  often  the  seat  of  gummatous  inflammation, 
which  may  lead  to  necrosis  of  the  laryngeal  cartilages  and  consider- 
able destruction,  with  subsequent  contraction  and  obstruction. 
Syphilitic  stricture  of  the  rectum  is  almost  confined  to  women. 

PROGNOSIS    AND    TREATMENT    OF    ACQUIRED    SYPHILIS 

Prognosis. — In  modern  times  syphilis  is  by  no  means  the 
formidable  disease  which  it  was  when  first  introduced  into  Europe, 
but  even  now,  if  it  be  introduced  into  virgin  communities,  it  runs  a 
very  much  more  severe  course  than  under  ordinary  circumstances 
is  the  case.     The  modern  alleviation  in  the  course  of  the  disease 


IX  PROGNOSIS   OF  ACQUIRED   SYPHILIS  191 

is  no  doubt  in  large  measure  due  to  great  advancement  in  diagnosis 
and  greater  skill  in  treatment ;  but  it  would  seem  probable  that 
there  is,  as  it  were,  some  degree  of  immunity  conferred  on  those 
born  in  communities  in  which  syphilis  has  been  long  endemic. 
Syphilis  is  certainly  a  curable  disease,  and  the  fact  that  re-infection 
occasionally  occurs  is  the  strongest  argument  in  support  of  this 
statement.  In  the  course  of  time  the  disease  tends  to  expend  its 
energy  and  to  die  out,  and  this  even  without  mercurial  treatment. 
We  should,  therefore,  naturally  expect  that  a  prolonged  and 
judicious  course  of  this  drug  would  hasten  recovery  and  eliminate 
the  poison  from  the  system.  Berkeley  Hill  says :  "  Although  we 
cannot  assure  a  patient  that  he  is  cured  beyond  possibility  of  a 
relapse,  experience  shows  that  if  a  sufficient  and  properly  prolonged 
course  of  treatment  has  been  carried  out  from  an  early  period,  the 
patient  may  expect  to  go  through  life  with  scarcely  more  appreciable 
risk  than  one  who  has  never  had  the  disease."  As  already  stated, 
in  discussing  etiology,  some  persons  prove  to  a  certain  extent 
refractory  to  the  poison  of  syphilis,  whereas  others  are  especially 
prone ;  but  it  is  noticeable  that  in  all  cases  of  syphilis,  as  indeed  of 
any  other  general  disease,  the  severity  of  its  course  is  in  great 
measure  dependent  upon  the  general  health  and  no  less  upon  the 
habits  of  the  victim.  In  the  majority  of  cases  no  serious  symptoms 
occur,  and  the  patient  remains  practically  free  from  all  manifestations 
of  the  disease  after  the  first  six  months  provided  he  has  been 
properly  treated ;  in  some  cases  the  manifest  lesions  disappear  even 
earlier  than  this,  and  of  this  fact  the  patient  should  be  made 
acquainted,  otherwise  he  may  neglect  to  continue  under  treatment. 
Chronic  alcoholism,  renal  disease,  tubercle,  and  a  strumous  diathesis 
add  to  the  gravity  of  the  prognosis,  since  such  conditions  materially 
impair  the  general  health,  and  the  two  first  interfere  with  assimila- 
tion and  the  destruction  of  waste  products ;  there  is  probably  no 
condition  which  is  more  serious  in  a  case  of  syphilis  than  chronic 
alcoholism,  in  the  rich  it  is  too  often  associated  with  a  generally 
irregular  habit  of  life,  and  in  the  poor  it  is  indulged  in  at  the 
expense  of  proper  food,  lodging,  and  clothing.  In  patients  over  the 
age  of  forty,  when  the  disease  is  contracted,  it  is  liable  to  run  a 
long  and  intractable  course.  But  little  real  information  as  regards 
the  ultimate  prognosis  can  be  gained  from  the  appearance  of  the 
primary  lesion  and  the  secondary  manifestations,  although  some 
consider  that  a  short  incubative  stage,  followed  by  a  chancre  which 
is  extensively  indurated  and  prone  to  ulcerate,  heralds  a  severe  form 
of  the  disease.      Indeed,  in  many  cases  a  small  insignificant  sore  is 


192  MANUAL   OF   SURGERY  chap. 

followed  by  severe  and  persistent  symptoms ;  this  may,  of  course, 
be  possibly  due  to  the  fact  that  such  a  sore  being  lightly  regarded 
by  the  patient  is  neglected.  Extra-genital  chancres  may  also  be 
followed  by  severe  symptoms,  but  this  again  is  dependent  upon  the 
fact  that  they  are  often  difficult  of  recognition,  and  hence  mercurial 
treatment  is  delayed  until  an  unmistakable  syphilide  clears  up  the 
diagnosis ;  there  is  no  reason  to  suppose  that  a  chancre,  say  on  the 
finger,  should  be  more  virulent  than  one  on  the  penis,  provided 
both  are  placed  under  the  same  conditions  as  regards  treatment. 
With  regard  to  the  ultimate  prognosis  from  the  appearance  and 
persistence  of  the  secondary  lesions  it  may  be  generally  stated  that, 
if  these  be  marked,  tertiary  lesions  will  either  be  very  slight  or 
absent,  perhaps  because  the  virulence  of  the  poison  is  in  large 
measure  expended  on  these  lesions,  but  no  doubt  also  because  it 
is  just  in  these  cases  that  treatment  is  most  energetically  and 
assiduously  carried  out  for  a  lengthened  period.  General  glandular 
enlargement  is  often  indicative  of  a  severe  attack.  Tertiary 
symptoms  do  not  occur  in  more  than  about  5  per  cent  of  all 
cases  am.ong  better  class  patients  under  private  treatment,  but  in 
the  case  of  the  poorer  hospital  out-patients  about  15  per  cent 
suffer. 

Treatment. — The  preventive  treatment  consists  in  personal 
cleanliness  and  avoidance  of  contagion.  Circumcision  doubtless 
diminishes  the  risk  of  infection  of  all  venereal  diseases,  and  it  may 
here  be  properly  pointed  out  that  this  slight  operation  is  one  which 
might  be  very  wisely  performed  in  many  children  in  whom  it  is 
neglected.  There  is  little  doubt  that  the  Jews  instituted  circumcision 
on  hygienic  rather  than  on  religious  grounds.  The  reinforcement  of 
the  Contagious  Diseases  Act  is  much  to  be  desired. 

The  contraction  of  marriage^  even  under  the  most  favourable 
circumstances,  should  never  be  permitted  until  the  expiration  of 
two  years  from  the  date  of  inoculation,  and  even  then  no  person 
should  be  allowed  to  marry  if  active  signs  of  secondary  syphilis  are 
or  have  been  present  within  the  past  six  months,  no  matter 
how  long  after  infection  they  may  appear,  for  transmission  to  the 
offspring  has  been  known  after  miany  years.  It  is  probable  that  the 
power  of  transmission  of  the  disease  to  their  offspring  lasts  longer  in 
women  than  in  men. 

Curative  treatment. — The  curative  treatment  of  syphilis  to  be 
entirely  satisfactory  must  be  undertaken  from  twostdndpoints:  (i)  The 
poison  itself  must  be  destroyed  by  the  use  of  mercury,  and  its  later 
effects  removed  by  the  iodides ;  and  (2)  the  patient  must  receive 


IX  TREATMENT  OF  ACQUIRED  SYPHILIS  193 

such  treatment  as  is  calculated  to  counteract  or  minimise  any 
condition  of  ill-health  or  any  peculiar  diathesis  of  which  he  may  be 
the  subject,  and  which,  if  left  untreated,  may  render  him,  so  to 
speak,  a  more  fitting  culture  medium  for  the  syphilitic  virus.  It 
nmst  further  be  remembered  that  the  knowledge  that  he  is  syphilitic, 
and  the  exaggerated  dread  of  the  uftimate  consequences  of  the 
disease,  which  he  probably  entertains,  added  to  the  depressing 
effects  of  a  prolonged  mercurial  course,  may  further  accentuate  any 
condition  of  ill-health  of  which  he  may  be  the  subject. 

During  the  primary  and  secondary  stages  of  syphilis,  mercury  is 
a  specific,  and  tertiary  lesions  are  equally  influenced  by  iodides. 
The  non-mercurial  treatment  of  syphilis  is  practically  no  treatment 
at  all,  and  the  improvement  which  will  undoubtedly  occur,  and 
which  is  attributed,  by  its  supporters,  to  this  method  is  merely  due 
to  the  curative  effects  of  time,  for,  as  has  already  been  stated, 
syphilitic  lesions  tend  to  undergo  spontaneous  cure,  and  such  im- 
provement would  have  equally  ensued  had  no  treatment  been 
adopted.  The  iodides  of  potassium,  sodium,  and  ammonium  are 
especially  useful  in  the  tertiary  stage,  but  in  some  cases  may  be 
used  with  advantage  during  the  secondary.  The  vegetable  bitters, 
cod-liver  oil,  maltine,  iron,  quinine,  Fellows'  syrup,  or  the  mineral 
acids  may  be  given  with  advantage  to  women,  and  to  strumous  or 
weakly  patients,  and  should  usually  be  administered  to  all  when  the 
mercurial  course  is  temporarily  intermitted ;  but  these  drugs  are 
adjuvants  only,  and  are  in  no  sense  to  be  regarded  as  specifics. 

Under  ordinary  circumstances  no  special  alteration  in  the 
patient's  habits  and  mode  of  life  is  necessary,  but  if  these  are  of  an 
unhealthy  nature,  a  more  healthy  regime  must  be  prescribed ;  while 
the  rich  and  luxurious  must  be  w^arned  against  over-indulgence,  the 
dietary  of  the  poor  must  be  made  as  good  as  circumstances  permit, 
and  alcoholic  excess  must  be  strenuously  interdicted  in  both.  As  a 
rule,  malt  liquor  is  not  w^ell  borne  by  those  undergoing  a  mercurial 
course,  but  if  the  patient  is  feeble  and  his  health  poor,  a  glass  of 
stout  in  the  middle  of  the  day  may  be  beneficial.  Fruit  and  green 
vegetables  sometimes  occasion  gastro- intestinal  disturbance,  and 
must  then  be  prohibited.  The  diet  must  be  generous  and  consist 
chiefly  of  fish,  meat,  poultry,  milk,  and  eggs,  with  a  very  moderate 
allowance  of  wine.  The  bow^els,  kidneys,  and  skin  should  be  kept 
acting  regularly,  and  a  warm  bath  daily  is  beneficial.  The  hours 
of  work  must  not  be  excessive,  and  the  patient  should  retire  to  bed 
early  and  have  at  least  eight  hours'  sleep.  Outdoor  exercise  is 
beneficial,  but  it  should  never  induce  fatigue.  The  clothing  niuot  be 
VOL.  I  o 


194 


MANUAL   OF   SURGERY  chap. 


warm  and  cold  should  be  carefully  avoided,  as  patients  taking  mercury 
are  sometimes  very  susceptible  to  its  influence.  It  is  absolutely 
necessary  to  impress  upon  the  patient  the  fact  that  although,  under 
treatment,  his  symptoms  will  rapidly  clear  up,  and  that  he  will 
perhaps  never  show  any  others,  yet  that  he  must  still  continue  under 
treatment  and  observation  ;  if  it  is  found  necessary  to  temporarily 
intermit  the  mercurial  course,  he  should  further  be  warned  that  he 
must  not  be  surprised  or  alarmed  if  a  slight  eruption  makes  its 
appearance  during  the  intermission,  and  that  such  eruption  will 
never  be  serious  and  will  rapidly  disappear  when  the  treatment  is 
resumed.  At  the  present  day  syphiHs  is  popularly  regarded  with  a 
degree  of  fear  and  dread  which,  under  proper  treatment,  is  not 
justified  by  results ;  this  should  be  thoroughly  explained  to  the 
patient,  who  should  be  encouraged  and  reassured  as  to  his  ultimate 
complete  recovery,  otherwise  his  natural  anxiety  may  develop  a 
condition  of  extreme  mental  dejection,  with  perhaps  that  state  which 
is  almost  as  serious  to  the  patient  as  is  syphilis  itself — syphilophobia. 

Mercury. — When  a  mercurial  course  is  entered  upon  the 
surgeon  should  satisfy  himself  that  the  teeth  are  sound,  and  if  any 
are  decayed  a  dentist  should  be  consulted.  In  whatever  way 
mercury  is  administered,  its  action  must  be  supervised,  so  that  on 
the  appearance  of  any  symptoms  indicative  of  an  excessive  dose, 
the  drug  may  be  stopped  and  appropriate  measures  adopted. 

No  one  preparation  of  mercury  is  applicable  to  all  persons,  or 
to  all  syphilitic  manifestations,  and  if  one  prescription  does  not 
suit  the  patient  some  other  must  be  tried;  with  a  httle  care  a 
preparation  can  usually  be  found  which  is  well  tolerated  and 
efficient.  There  is  no  occasion  to  push  the  drug  until  the  gums 
are  tender,  as  has  been  advised  by  some. 

Mercurial  salivation  is  easily  produced  in  some  persons,  with 
difficulty  in  others.  Salivation  is  characterised  by  swelling  and 
tenderness  of  the  gums  and  the  appearance  of  a  blue  line  at  their 
margins  ;  the  salivary  glands  are  swollen  and  tender  and  the  saliva 
is  increased  in  quantity;  griping  pains  in  the  abdomen,  with 
purging,  are  common.  In  bad  cases  the  gums  may  slough,  the 
teeth  loosen  and  drop  out,  and  the  alveolar  borders  of  the  jaws 
necrose.  Mercurial  ulcers  must  be  diagnosed  from  syphihtic ; 
they  may  affect  the  gums,  tongue,  cheeks,  and  lips,  are  accompanied 
by  considerable  swelling  and  pain,  and  are  surrounded  by  a  red  in- 
flamed area.      The  breath  has  a  pecuharly  offensive  odour. 

If  mercurial  salivation  is  induced,  the  mercury  must  be  stopped 
and  a  saline  aperient  ordered.     The  mouth  should  be  frequently 


IX  TREATMENT   OF   ACQUIRED   SYPHILIS  195 

rinsed  with  an  astringent  lotion  of  alum  or  chlorate  of  potash 
(gr.  10  ad  5i.),  with  glycerine  and  rose  water.  If  the  dose  of 
mercury  employed  is  likely  to  cause  spongy  gums  or  yet  more 
serious  results,  great  care  must  be  paid  in  thoroughly  cleansing  the 
teeth  twice  daily,  and  the  patient  may  be  directed  to  rinse  out 
his  mouth  with  the  alum  or  potash  lotion  three  or  four  times  a  day. 
A  very  useful  lotion  for  this  purpose  is  one  of  trisulphate  of 
alumina,  gr.  5  ;  acetate  of  lead,  gr.  2  ;  aqua  fioris  aurantii,  5i. 

^lercury  may  be  administered  by  the  mouth,  by  inunction,  by 
fumigation,  or  by  hypodermic  or  intra-venous  injection. 

Mercury  by  the  mouth  is  the  most  convenient  method,  and  is 
usually  given  in  the  form  of  pills  and  in  combination  with  opium  or 
Dover's  powder  to  prevent  purging.  Grey  powder,  blue  pill,  or  the 
tannate  of  mercury  in  one-grain  doses,  with  an  equal  quantity  of 
Dover's  powder  and  extract  of  gentian  may  be  given  thrice  daily 
after  meals,  or  more  often  if  a  larger  dose  seems  necessary.  If  the 
patient  is  weak  and  feeble,  quinine,  iron,  or  strychnia  may  be 
combined  with  the  pill.  One  of  these  forms  of  mercury  will 
usually  be  well  tolerated  by  most  patients ;  but  should  salivation, 
griping  pains,  diarrhcta,  or  intestinal  disturbance  be  excited,  the 
amount  of  Dover's  powder  must  be  increased,  or  pure  opium, 
gr.  y--J,  substituted;  pepsin  or  extract  of  lettuce  are  also 
useful. 

If  none  of  these  preparations  are  tolerated,  or  if  they  do  not 
produce  the  desired  result,  some  other  form  must  be  prescribed  or 
the  dose  decreased.  The  success  of  treatment  and  the  comfort  to 
the  patient  during  it  are  materially  influenced  by  the  discovery  of 
that  preparation  and  that  dose  which  can  be  taken  without  in- 
convenience ;  if  the  patient  proves  intolerant,  more  harm  than 
good  may  result. 

The  perchloride  (-3V  -  -§-  grain),  combined  with  gr.  3-4  of 
iodide  of  potassium,  is  a  good  preparation  and  well  borne  by  most 
people.  It  is  best  given  in  a  fluid  form,  as  there  is  considerable 
difficulty  in  accurately  dispensing  iodide  of  potassium  in  pills.  The 
green  and  red  iodides  of  mercury,  Donovan's  solution,  or  Plummer's 
pill  often  prove  most  effectual  in  persistent  and  relapsing  skin 
lesions. 

The  iodides  of  mercury  must  be  combined  with  opium,  and 
as  they  are  very  liable  to  decompose,  the  pills  should  not  be  kept 
too  long.  The  green  iodide  is  preferable  to  the  red,  as  it  is  less 
irritating. 

Mepeupy    by    inunetion  is  useful  in  cases   where   the  patient 


196  MANUAL  OF   SURGERY  chap. 

proves  intolerant  of  it  by  the  mouth,  or  when  it  is  necessary  to 
bring  him  rapidly  under  its  influence.  It  has  the  disadvantage  of 
being  a  troublesome  and  dirty  method,  and  of  sometimes  producing 
considerable  irritation  and  eczema  of  the  skin,  especially  if  the 
oleate  (5  or  10  per  cent)  is  used. 

The  blue  ointment,  mixed  with  an  equal  part  of  lanolin,  is  the 
best  preparation,  and  one  or  two  drachms  of  the  mixture  should  be 
used  at  each  inunction,  which  is  best  made  into  the  loins,  groins, 
axillse,  or  upper  and  inner  aspect  of  the  thighs.  These  situations 
should  be  selected  alternately,  so  that  irritation  may  not  be  produced. 
Inunction  is  best  made  by  a  skilled  rubber,  but  can  be  conducted  by 
the  patient  himself  The  part  selected  should  be  carefully  cleaned, 
and  it  is  advisable  that  the  patient  should  have  a  warm  bath  before 
inunction,  which  should  be  made  at  night  just  before  going  to  bed. 
The  ointment  must  be  gently  rubbed  in  for  about  a  quarter  of  an 
hour,  in  front  of  a  fire  if  possible ;  the  part  is  then  covered  with 
flannel,  and  the  patient  should  retire  to  rest.  Inunction  should  be 
repeated  daily  for  three  periods  of  six  weeks  each,  with  one 
month's  rest  between.  The  gums  must  be  carefully  watched,  and 
the  alum,  potash,  or  alumina  mouth-wash  should  be  freely  used  to 
avoid  salivation. 

During  the  treatment  the  patient  must  be  warmly  clad  and 
avoid  cold ;  the  diet  must  be  liberal  and  generous,  and  cod-liver 
oil  and  tonics  should  be  given.  The  Aix-la-Chapelle  treatment 
practically  consists  in  mercurial  inunction  after  sulphur  baths, 
combined  with  the  observance  of  strict  dietary  and  hygienic  rules. 
During  treatment  by  inunction  the  patient  must  be  kept  under 
strict  supervision. 

Mercury  by  fumigation  is  especially  useful  when  it  is  necessary 
to  push  the  drug  and  bring  the  patient  rapidly  under  its  influence, 
and  when  there  is  a  persistent  skin  eruption.  Lees's  bath  is  the 
most  convenient  form,  and  from  20-30  grains  of  calomel  should  be 
used  at  each  sitting,  which  must  take  place  at  night  and  not  last 
more  than  a  quarter  of  an  hour.  The  patient,  stripped  and  sitting 
on  a  cane-bottomed  chair,  is  surrounded  by  a  cane-hoop  frame, 
with  a  woollen  cover  which  is  tied  round  the  neck  and  covered 
with  a  blanket.  Lees's  lamp  having  a  little  water  in  the  saucer  at 
the  top,  and  the  calomel  on  the  disc  is  put  beneath  the  chair  and 
lighted.  In  a  few  minutes  the  patient  is  bathed  in  perspiration, 
and  the  calomel  volatilises  and  is  deposited  on  the  skin.  When 
the  bath  is  over,  he  should  be  wrapped  in  a  warm  blanket  and 
placed  in  bed  by  an  attendant,  who  should  always  be  present  in 


IX  TREATMENT   OF  ACQUIRED   SYPHILIS  197 

case  faintness  is  induced.  Strong  and  vigorous  patients  may  have 
a  bath  daily,  but  the  weakly  and  feeble  should  not  have  one  more 
than  every  third  day.  Treatment  by  fumigation  rarely  causes 
salivation  but  is  ver)'  depressing,  and  during  it  the  patient  must  be 
very  careful  to  follow  the  general  rules  previously  laid  down ;  he 
must  avoid  cold,  take  moderate  exercise,  and  live  well.  He  should 
avoid  being  out  in  damp  weather  and  after  sun-down. 

Mercury  by  intra-muscular  or  intra-venous  injection  is  but 
little  used  in  this  country,  although  advocated  by  some.  It  should 
be  reser\'ed  for  those  rare  cases  in  which  all  other  means  of  treat- 
ment prove  ineffectual. 

A  variety  of  preparations  have  been  used  for  intra-muscular 
injection,  but  the  superiority  of  any  one  does  not  appear  to  be 
great. 

Either  of  the  following  preparations  may  be  employed ;  the 
sozoiodal  is  said  to  be  less  irritating  than  the  sal  alembroth  : — 

R     Hydrarg.  perchlor.  grs.  2,^- 
Ammon.  chloride,  grs.  16. 
Aq.  distill.  5ii. 
Ten  minims  ( =  J  gr.  sal  alembroth)  for  each  injection. 

R     Hydrarg.  sozoiodal,  grs.  5. 
Sodii  iodid.  grs.  10. 
Aq.  distill.      ]\  200. 
Ten  to  fifteen  minims  for  each  injection. 

The  injections  may  be  made  (under  aseptic  precautions)  each 
day  or  at  longer  intervals,  according  to  the  strength  of  the  patient 
and  the  effect  produced.  If  used  daily,  the  course  should  extend 
over  about  a  month.  Perhaps  the  most  satisfactory  method  is  to 
give  an  injection  once  a  week  for  two  months,  then  once  a  fort- 
night for  three  months,  followed  by  monthly  injections  until  the 
end  of  three  years  from  the  date  of  injection. 

The  outer  part  of  the  thigh,  the  loin,  or  buttock  are  the  most 
suitable  seats,  and  the  injection  must  be  made  deeply  into  the 
muscles ;  it  often  causes  considerable  pain,  but  suppuration  is  rare. 
In  some  cases  symptoms  of  mercurial  poisoning  of  more  or  less 
gra\'ity  ensue.  This  method  of  treatment  is  not  to  be  recom- 
mended, nor  is  there  reason  to  suppose  that  it  is  more  efficacious 
than  when  the  drug  is  taken  by  the  mouth.  The  intra-venous 
method  seems  still  less  to  be  advisable. 

Duration  of  a  mercurial  course. — The  course  of  treatment 


198  MANUAL   OF  SURGERY  chap. 

should  extend  over  two  years  in  all  cases,  and  longer  if  the  disease 

is  severe  and  the  symptoms  persistent.  To  obtain  the  full  benefit 
of  mercury,  it  must  be  given  in  small  doses  over  a  long  period  of 
time. 

The  plan  I  usually  adopt  is  to  administer  mercury  continuously 
for  the  first  nine  months,  only  remitting  it  for  a  few  days  if  the 
gums  become  tender.  During  the  tenth  month  the  mercury  is 
discontinued,  and  cod-liver  oil.  Fellows'  syrup,  or  any  suitable  tonic 
given  ;  during  the  eleventh  and  twelfth  months  treatment  is  re- 
sumed. During  the  second  year  the  patient  should  take  mercury 
in  smaller  doses  every  alternate  month,  and  during  the  third, 
fourth,  and  fifth  years  I  usually  recommend  him  to  take  a  mixture 
of  the  perchloride  with  iodide  of  potassium  for  a  month.  If  this 
course  be  followed,  and  the  mercury  is  given  in  a  form  suitable  to 
the  patient,  it  can  be  well  borne  and,  in  most  cases,  will  prove 
successful.  If  the  patient  suffers  severely  from  the  disease,  treat- 
ment must  be  continued  over  a  longer  period. 

The  iodides  of  potassitim,  sodium,  and  ammonium  are  specially 
useful  in  the  tertiary  stage,  and  may  be  advantageously  given  with 
small  doses  of  the  perchloride  of  mercury.  All  iodides  are  de- 
pressing, and  some  people  are  peculiarly  intolerant  of  them, 
symptoms  of  poisoning  (iodism)  appearing  after  very  small  doses. 

lodisjn  is  characterised  by  coryza  and  lacrymation,  dryness  of 
the  throat  and  fauces,  frontal  headache,  and  increase  in  the  nasal 
mucus,  with  the  usual  signs  of  an  ordinary  cold  in  the  head. 
There  is  often  considerable  mental  depression  and  bodily  lassitude. 
Acne  and  various  skin  eruptions,  sometimes  severe  and  extensive, 
may  be  produced,  and  should  such  signs  appear  the  dose  must  be 
diminished. 

It  is  surprising  how  much  idiosyncrasy  influences  the  action  of 
iodides,  some  patients  responding  well  to  quite  small  doses,  while 
others  require  the  drug  to  be  steadily  pushed  as  tolerance  is  estab- 
lished ;  iodides  should  be  combined  with  carbonate  of  ammonia  and 
a  vegetable  bitter  to  counteract,  in  some  measure,  their  depressing 
effects. 

During  the  secondary  stage  iodides  are  often  useful,  especially 
if  the  symptoms  do  not  yield  to  mercury.  Ten  grains  at  night  is 
the  most  useful  and  least  depressing  method  of  administration. 

Serum  treatment. — Recently,  blood-serum  of  syphiHtic  patients 
has  been  used  hypodermically  as  a  remedial  agent.  Streptococcus 
serum  has  also  been  used,  and  Rudolph  reports  two  cases  in  which 
accidental  erysipelas,  occurring  in  a  syphilitic  patient,  was  attended 


IX     SPECIAL  TREATiMENT  OF  SYPHILITIC  LESIONS  199 

by  rapid  and  beneficial  results ;  the  erysipelas  apparently  having  in 
one  such  case  more  potent  curative  effects  than  had  mercurial 
treatment.  At  present  no  definite  statements  on  this  method  of 
treatment  can  be  made. 


SPECIAL    TREATMENT    OF    SYPHILITIC    LESIONS 

The  primary  lesion,  when  non-ulcerating  and  occurring  as  a 
papule,  needs  no  dressing,  but  should  be  covered  up  to  prevent 
irritation.  The  ulcerated  sore  must  be  kept  clean  and  covered 
with  a  piece  of  lint  saturated  with  black  wash,  or  it  may  be  dusted 
with  calomel.  If  phagedaenic  symptoms  appear,  the  treatment 
must  be  more  energetic  (vide  y>-  118).  If  the  sore  be  concealed 
by  a  tight  foreskin,  this  should  be  slit  up.  Excision  of  the  sore  is 
useless,  infection  of  the  blood  having  already  occurred. 

Non-uleerated  skin  affections  do  not  usually  require  any  local 
treatment,  but  if  they  are  very  persistent,  as  in  palmar  psoriasis,  a 
little  mercury  ointment  may  be  rubbed  into  the  patches,  or  they 
may  be  covered  with  Unna's  mercurial  plaster.  Internally,  the 
green  iodide  of  mercury  or  Donovan's  solution  are  most  useful,  and 
may  be  well  combined  with  the  iodide  of  potassium.  Widespread 
and  persistent  eruptions  may  require  treatment  by  fumigation. 

Ulcers  of  the  skin  must  be  kept  scrupulously  clean  and  all 
scabs  and  crusts  removed ;  usually  a  simple  unirritating  lotion,  such 
as  boracic  acid,  is  all  that  is  needed  locally,  healing  being  dependent 
on  the  administration  of  anti-syphilitic  remedies.  In  persistent 
cases,  healing  may  be  hastened  by  the  application  of  mild  mer- 
curial ointments.  If  the  lesions  inflame  and  tend  to  spread,  the 
acid  nitrate  of  mercury  will  arrest  the  process. 

Condylomata  and  mucous  tubercles  must  be  kept  clean  and 
as  dry  as  possible.  They  should  be  dusted  with  equal  parts  of 
calomel  and  starch  powder  or  zinc  oxide  twice  a  day  after  being 
washed  and  dried.  When  situated  in  contact  with  a  skin  surface 
{e.g.  fold  of  the  nates),  condylomata  should  be  covered  with  hnt  so 
as  to  prevent  auto-inoculation. 

Lesions  of  the  mucous  membranes  usually  heal  rapidly  if  all 
sources  of  irritation  be  removed  and  a  mercurial  lotion  applied. 
In  the  case  of  the  throat,  mouth,  and  tongue,  smoking  should  be 
prohibited  and  the  patient  warned  against  hot  drinks,  mustard, 
sauces,  and  similar  things  likely  to  cause  irritation.  Astringent  and 
mercurial  gargles  and  mouth  washes  should  be  prescribed.  Alum 
or  chlorate  of  potash  (gr.  10  ad  51.),  with  glycerine  and  rose  water,  or 


200  MANUAL  OF   SURGERY  chap. 

perchloride  of  mercury  (gr.  J  to  gr.  i)  are  the  best  gargles. 
If  the  throat  is  very  bad  and  does  not  readily  yield  to  this,  the 
mercury  must  be  increased  to  two  grains  to  the  ounce.  In  some 
cases  it  is  necessary  to  use  very  strong  solutions  (hyd.  perchlor., 
gr.  4,  or  hyd.  cyanide,  gr.  2),  and  these  had  better  be  applied  with 
a  camel's-hair  brush  by  the  surgeon.  The  patient  should  always 
be  warned  of  the  poisonous  nature  of  mercurial  gargles. 

Secondary  ulcers  of  the  tongue  and  cheeks  are  sometimes  very 
persistent  and  painful,  and  if  the  above  lotions  do  not  produce  a 
cure,  the  ulcers  may  be  touched  with  nitrate  of  silver,  or  daily 
painted  with  a  solution  of  twenty  grains  of  the  salt  to  the  ounce  of 
glycerine  and  water.  Chromic  acid  in  10  per  cent  solution,  or 
crystals  of  salicylate  of  soda  are  also  useful  local  applications ; 
under  the  former  these  ulcers  often  heal  with  great  rapidity. 

CONGENITAL    OR    INHERITED    SYPHILIS 

Transmission  of  syphilis.  —  Syphilis  may  be  inherited 
through  one  or  both  parents.  In  the  latter  case  inheritance  is 
more  certain  and  the  disease  more  severe.  Inheritance  through 
the  father  alone  renders  the  mother  syphilitic  through  the  foetus ; 
although  she  may  be  in  apparent  health  and  not  show  traces  of 
syphilis  on  superficial  examination,  yet  a  searching  inquiry  and 
examination  will  often  prove  that  infection  has  occurred ;  and 
even  if  no  such  evidence  be  forthcoming,  the  fact  that  she  has 
been  inoculated  and  thus  protected  is  definitely  proved,  since  she 
is,  with  very  rare  exceptions,  immune  (Colles's  Law).  The  mother 
may  be  infected  before  or  after  conception ;  in  the  latter  case  the 
child  may  escape,  provided  gestation  is  advanced,  and  usually  does 
so  if  the  mother  is  not  inoculated  before  the  seventh  month. 

Syphilis  is  transmissible  to  the  offspring  during  the  primary  and 
secondary  stages,  but  not  in  the  tertiary.  The  more  recent  and 
severe  the  infection,  the  more  certainly  and  severely  will  the  child 
suffer,  its  chances  of  escape  increasing  with  the  remoteness  of 
infection  of  the  parents  ;  thus  a  recently  infected  woman  will,  if 
she  conceive,  abort ;  in  later  conceptions  abortion  may  yet  occur, 
but  at  a  later  period  of  gestation ;  later  still,  a  living  syphilitic 
child  is  born  and  subsequent  children  suffer  less  severely  or  escape. 
To  put  it  shortly,  the  chances  of  infection  of  the  child  and  the 
severity  of  that  infection  diminish  with  time. 

The  transmissive  power  in  a  woman  usually  lasts  during  the 
first  four  years  of  the  disease.     Transmission  to  the  second  genera- 


IX  CONGENITAL  OR   INHERITED   SYPHILIS        201 

tion  does  not  occur.  Hereditary  syphilitics  are  usually  immune  to 
the  acquired  disease ;  but  this  immunity  is  not  invariable,  nor 
should  we  expect  it  to  be  so  in  view  of  the  fact  that  second  infec- 
tion of  acquired  syphilis,  although  rare,  is  possible. 

Abortion  in  acquired  syphilis.  —  Careful  treatment  of  the 
mother  during  her  pregnancy  may  prevent  abortion,  and  the  child, 
although  it  ver)'  rarely  escapes  altogether  in  cases  of  recent  infec- 
tion, may  suffer  but  little.  Abortion  may  be  due  to  disease  of  the 
placenta  and  occlusion  of  the  vessels,  to  disease  of  the  uterine 
mucous  membrane,  or  to  the  general  constitutional  disturbance 
attending  the  onset  of  the  secondary  stage.  Grave  syphilitic 
disease  of  the  foetus  occasions  its  death  and  consequent  expulsion. 

Course  and  symptoms  of  congenital  syphilis. — The  symp- 
toms differ  only  in  degree  and  not  in  essential  characters  from  those 
met  with  in  acquired  syphilis,  but  since  they  attack  rapidly-growing 
tissues  instead  of  matured  ones,  their  effects  are  more  serious  and 
lasting.  The  main  stress  of  the  disease  falls  upon  the  skin  and 
bones,  but  in  very  bad  cases  the  viscera  are  affected.  One  notice- 
able feature  of  congenital  syphilis  is  the  occurrence  of  secondary 
and  tertiary  lesions  at  the  same  time.  The  symptoms  occur  at  an 
early  and  a  late  stage,  the  former  comprising  the  first  few  weeks 
of  life,  the  latter  childhood  and  puberty.  Hutchinson  and  others 
assert  that  the  early  stage  may  be  absent,  but  this  is  very  doubtful. 
These  stages  are  usually  separated  by  a  period  of  apparent  health. 
They  correspond  with  the  secondary  and  tertiary  stages  of  the 
acquired  disease,  but  the  latter  shows  certain  peculiarities  in  the 
inherited  form  (see  p.  205). 

The  early  stage. — The  primary  sore  Is,  of  course,  absent ; 
should  one  be  detected,  the  case  is  one  of  acquired  not  congenital 
syphilis.  In  cases  of  recent  infection  of  the  mother,  the  child  may 
be  born  with  syphilitic  lesions  and  usually  soon  dies ;  more  fre- 
quently the  symptoms  appear  within  the  first  six  weeks,  but  the 
later  they  manifest  themselves  the  less  serious  will  they  be.  At 
birth  the  child  may  be  apparently  healthy  and  fat,  but  ver)'  soon  it 
shows  general  deterioration  of  the  health  and  becomes  pale,  anaemic, 
and  emaciated ;  the  skin  loses  its  softness,  is  shrivelled,  wasted, 
wrinkled,  and  of  a  muddy  tint,  and  the  child  has  a  prematurely 
aged  appearance.     Iritis  is  occasionally  present. 

During  the  evolution  of  this  stage  the  child  not  infrequently 
succumbs,  the  end  being  ushered  in  by  severe  and  increasing 
anaemia. 

Affections  of  the   skin  and  mucous   membranes. — Macular 


202  MANUAL  OF   SURGERY  chap. 

and  papular  rashes  of  the  skin  and  mucous  membranes  are,  as  in 
the  acquired  disease,  early  and  common  manifestations.  Coppery 
papules  usually  occur  in  groups,  and  chiefly  affect  the  lower  half  of 
the  body,  especially  the  buttocks,  nates,  genitals,  and  groins ;  in 
which  situations,  as  they  are  kept  moist  and  warm,  the  papules 
appear  as  mucous  tubercles.  Mucous  tubercles  also  affect  the  lips, 
cheeks,  tongue,  and  throat.  A  most  characteristic  and  early  sign 
is  the  inflammation  and  formation  of  mucous  patches  and  ulcers  on 
the  nasal  mucous  membrane,  which  is  considerably  swollen  and 
encrusted  with  thick  yellow  scabs,  and  secretes  a  copious,  tenacious, 
muco-purulent  material.  The  nasal  mischief  interferes  with  respira- 
tion and  causes  "  snuflles  "  ;  the  respiratory  difficulty  renders  sucking 
difficult,  and  hence  the  child  is  often  fretful  and  restless,  and  its 
nutrition  further  impaired ;  moreover,  cold  is  often  contracted,  and 
may  terminate  in  bronchitis  or  broncho-pneumonia.  The  inflam- 
matory affection  of  the  mucous  membrane  may  extend  to  and  cause 
necrosis  of  the  bones  of  the  nasal  fossae,  or  their  development  may 
be  so  impaired  that  the  bridge  of  the  nose  is  permanently  depressed. 
As  in  the  acquired  disease,  the  mucous  membrane  of  the  larynx  is 
often  affected  and  the  child's  cry  is  harsh  and  hoarse. 

Mucous  tubercles  at  the  angles  of  the  mouth  or  round  the 
nostrils  may,  owing  to  the  mobility  of  the  parts,  lead  to  trouble- 
some Assuring ;  when  these  fissures  heal,  fine  white  radiating  scars 
are  left.  Mucous  tubercles  of  the  mouth  and  tongue  are  common, 
and  cause  pain  during  sucking ;  stomatitis — not  to  be  mistaken  for 
aphthae — may  give  considerable  trouble  and  lead  to  sloughing  of 
the  gums,  to  the  detriment  of  the  primary  teeth,  which  are  often 
discoloured,  decay  early,  and  crumble  away. 

The  vesicular  and  pustular  syphilides  may  be  present  at  birth, 
or  occiir  within  a  few  days ;  they  indicate  a  severe  form  of  the 
disease,  and  are  of  serious  om^en. 

Syphilitic  pemphigus  (Fig.  37,  p.  183)  affects  the  soles  and 
palms,  and  spreads  up  the  limbs  to  the  trunk.  Large  bullae  appear 
situated  on  dark  red  papules ;  they  soon  suppurate,  burst,  and  scab 
over,  ulceration  spreading  beneath  the  scabs.  Non-syphilitic  pem- 
phigus does  not  affect  the  soles  or  palms. 

The  nodular  syphilides  and  subcutaneous  gummata  do  not 
usually  occur  until  the  late  period  of  hereditary  syphilis,  and  are 
always  rare. 

Affections  of  the  hair  and  nails  are  similar  to  those  met  with 
in  the  acquired  disease  (p.  185). 

Affections  of  the  lymphatic  glands. — -Coincident   with    the 


IX  CONGENITAL   OR    INHERITED   SYPHILIS        203 

appearance  of  the  skin  lesions,  the  lymphatic  glands  in  various 
parts  of  the  body  may,  as  in  acquired  syphilis,  be  enlarged  and 
tender ;  sometimes  the  skin  over  them  is  inflamed  and  ulcerates, 
the  exposed  glands  disintegrate,  and  the  process  closely  simulates 
tubercle. 

Affections  of  the  viscera  are  ver)'  serious,  and  usually  appear 
early,  or  may  be  present  at  birth.  Interstitial  inflammation, 
gummata,  and  amyloid  degeneration  are  the  morbid  conditions,  the 
liver  and  spleen  being  their  usual  site ;  but  no  organ  is  exempt. 
The  affected  viscus  may  be  found  to  be  enlarged.  Anasarca,  with 
purpuric  spots,  is  an  occasional  associated  condition. 

Affections  of  the  bones  and  joints  may  be  early  or  late,  and 
may  implicate  the  flat  bones  of  the  skull  or  the  periosteum  or 
epiphysar}'  lines  of  the  long  bones,  especially  those  of  the  forearm 
and  leg.  Any  of  the  bone  or  joint  lesions  met  with  in  acquired 
syphihs  may  occur  in  the  inherited  disease,  but  two  forms  are  to 
be  specially  mentioned:  (i)  epiphysitis  or  osteo-chondritis  with 
pseudo-paralysis,  and  (2)  chronic  effusion  into  one  or  more  joints. 
When  the  disease  affects  the  periosteum,  inflammation  is  excited, 
and  layers  of  soft,  white,  porous  new  bone  are  deposited  on,  and 
parallel  with,  the  long  axis  of  the  shaft,  from  which  they  are  clearly 
demarcated.  Sometimes  this  new  tissue  is  more  highly  vascular 
and  fibrous,  resembling  that  formed  in  rickets  (rachitic  or  spongioid 
form),  or  the  two  forms  may  be  combined.  As  these  periosteal 
changes  advance,  the  normal  shaft  undergoes  decalcification,  and 
hence  spontaneous  fracture  or  bending  is  not  uncommon.  The 
deposit  of  new  bone  may  lead  to  considerable  thickening  of  the  shaft. 

The  changes  in  the  epiphysary  line  closely  resemble  those  met 
with  in  rickets ;  thus  there  is  increased  cellular  proliferation  but 
imperfect  ossification,  and  the  cells  may  soften  and  form  gelatinous 
areas  like  fruit  jelly  (gelatiniform  atrophy).  The  end  of  the  bone 
is  considerably  enlarged,  through  the  deposit  of  new  tissue  from 
the  periosteum.  The  epiphysis  may  be  completely  separated  and 
suppuration  may  occur,  although  this  is  rare.  Occasionally  the 
joint  is  involved.  The  interference  with  the  process  of  growth  and 
development  leaves  the  bones  short  and  stunted.  When  the  bones 
are  very  soft — and  especially  if  they  are  broken — the  limb  hangs 
uselessly  and  appears  as  if  paralysed  (pseudo-paralysis).  When  the 
flat  bones  of  the  skull  are  affected  the  periosteum  is  usually  in- 
volved, but  gelatiniform  atrophy  is  not  so  common. 

Parrofs  bossing  and  craniotabes  are  thought  by  some  to  be 
essentially  syphilitic  in  nature,   while  others  consider  them   as    of 


204 


MANUAL   OF  SURGERY 


CHAP. 


Fig.    41.  —  Parrot's    bossing  of   the 
skull  in  a  congenitally  syphilitic 


rickety  origin.  It  is  probable  that  both  diseases  (and  they  are 
often  associated)  may  induce  these  changes,  and  that  craniotabes 
at  least  may  be  dependent  on  any  condition  of  general  ill-health 
impairing  nutrition.  Parrot's  bossing  and  craniotabes  may  be  met 
with  in  the  same  skull. 

Parrot's  bossing  is  dependent  on  inflammation  of  the  periosteum, 
and  consequent  heaping  up  of  soft,   spongy,   highly  vascular  new 

bone  of  a  deep  maroon  colour.  The 
new  bone  is  composed  of  large  medullary 
spaces,  with  perpendicular  trabeculas 
irregularly  arranged  round  the  Haversian 
canals  ;  when  the  active  stage  has  passed 
the  density  increases.  The  bossing  is 
remarkably  symmetrical  (Fig.  41),  is 
present  on  the  outer  table  only,  and 
follows  more  or  less  definite  Hnes.  It 
especially  affects  the  frontals,  parietals, 
and  peribregmatic  area,  at  the  same  tim.e 
respecting  the  frontal,  parietal,  and  oc- 
cipital eminences,  which  afford  a  striking 
change  ^lersEl  °' xt  contrast  to  the  affected  parts.  The 
anterior  fontaneiie  IS  widely  open  suturcs  may  be   cncroachcd    uDon    and 

and  the  two  halves  of  the  frontal  .  •'  ^ 

bone  are  separate.     (Westminster     obliterated,    SO  that   thc    full    dcVClopment 

Hospital      Museum,      No.      21B.         r     ^  i      n    •      •  •         i        --m        r        ^  n 

Drawn  by  c.  H.  Freeman.)         01  the  skull  IS  impaired,     i  hc  lontanelles 

may  close  prematurely  or  may  remain 
widely  open,  islands  of  new  bone  being  present  in  them.  The 
frontal  bosses  broaden  the  skull  and  give  it  the  peculiar  shape  and 
greater  breadth  so  often  seen  in  the  subjects  of  hereditary  syphilis 
(natiform  skull). 

Craniotabes  is  symmetrical,  but  is  often  more  marked  on  one 
side,  usually  the  right,  and  especially  affects  the  postero-inferior 
parietal  angle.  The  inner  table  of  the  bone  is  atrophied,  and  the 
small  depressions  produced  are  exaggerations  of  those  correspond- 
ing with  the  cerebral  convolutions.  Atrophy  leads  to  thinning,  and 
small  conical  pits  are  seen  on  the  inner  surface  of  the  skull ;  there 
may  be  a  fine  lacework  of  bony  tissue,  or  else  actual  perforaiion, 
the  dura  mater  and  periosteum  then  being  in  contact.  Numerous 
patches  of  atrophy  may  be  present,  and  can  be  detected  during  life 
as  weak  spots  yielding  to  the  pressure  of  the  finger.  The  atrophy 
proceeding  from  within  does  not  cause  bulging  externally,  since  the 
skull  is  supported  by  the  pillow ;  it  is  probable  that  the  atrophy  is 
induced  by  the  pressure  of  the  brain  on  predisposed  bones. 


IX  CONGENITAL  OR   INHERITED   SYPHILIS        205 

Craniotabes  is  rarely  present  before  the  third  month  of  hfe,  and 
all  traces  of  it  have  usually  disappeared  by  the  twelfth.  Parrot 
describes  cases  of  congenital  craniotabes  presenting  characters 
different  to  the  infantile  form.  In  these  the  affection  occurs  along 
the  margins  of  the  sagittal  suture  and  round  the  bregma,  and  small, 
dome-like  projections,  often  perforated  at  the  summit,  are  present 
externally.  These  are  supposed  to  be  due  to  the  absence  of 
external  support  counteracting  the  pressure  of  the  brain  within  ; 
which  pressure  is  exerted  on  the  vertex  of  the  skull,  since  the  head, 
in  ufero,  is  usually  the  most  dependent  part. 

The  late  stage. — The  symptoms  of  this  stage  are  in  many 
respects  similar  to  those  of  the  tertiary  period  in  acquired  syphilis, 
but  Hutchinson  is  doubtful  whether  they  ought  not  to  be  regarded  as 
secondary,  to  which,  in  some  respects  at  least,  they  have  a  greater 
resemblance.  Thus  the  lesions  are  usually  symmetrical,  and  tend 
to  spontaneous  cure  rather  than  to  persist  and  recur.  If  these 
symptoms  are  regarded  as  belonging  to  the  true  secondary'  stage, 
it  must  be  admitted  that  the  inherited  disease  has  no  tertiary 
period.  Symptoms  may  appear  at  any  time,  but  usually  do  so  at 
the  period  of  second  dentition  or  puberty,  or  later  still,  during 
the  final  stages  of  development  of  the  skeleton.  The  later  the 
symptoms  appear  the  better,  since  delay  in  their  manifestation 
argues  a  more  favourable  course,  and  they  are  less  likely  to  do 
serious  damage  to  tissues  more  mature.  Sometimes  the  late  stage 
follows  closely  on  the  early  symptoms,  in  other  cases  it  may  never 
appear.  The  lesions  of  the  late  stage  clinically  resemble  those  of 
tubercle,  and  the  diagnosis  often  depends  on  the  evidence  of 
previous  syphilitic  mischief,  the  general  appearance  of  the  child, 
and  the  effects  of  treatment.  The  appearance  of  a  syphilitic  child 
may  or  may  not  be  characteristic.  He  is,  in  consequence  of  the 
early  affections  of  the  bones,  often  stunted  and  dwarfed,  the  fore- 
head is  square  and  prominent,  the  bridge  of  the  nose  depressed, 
and  the  child  is  generally  ill-developed.  Fine  white  linear  scars  (the 
remains  of  fissures  and  mucous  tubercles)  are  not  uncommonly 
seen  at  the  angles  of  the  mouth  or  round  the  alae  nasi.  The  long 
bones  may  show  unmistakable  signs  of  periosteal  or  epiphysary 
disease,  but  it  must  be  remembered  that  these  signs  are  very  like 
the  changes  of  rickets.  Three  very  characteristic  features  of  in- 
herited syphilis  are  interstitial  keratitis,  malformation  of  the  upper 
central  incisor  teeth,  and  symmetrical  deafness,  unattended  or 
preceded  by  discharge  (Hutchinson's  triad). 

Affections  of  the  skin  in  the  late  stage  are  not  common,  but 


2o6  MANUAL   OF   SURGERY  chap. 

syphilitic  ''  lupus  "  and  gummatous  ulcers  of  the  legs  may  be  pre- 
sent. Chronic  osteitis  and  periostitis,  caries,  and  necrosis  are  not 
uncommon. 

Chronic  painless  effusion  may  take  place  into  a  joint,  usually 
the  knee,  accompanied  by  thickening  of  the  synovial  membrane. 
This  condition  may  persist  for  weeks  or  months,  but  gradually 
clears  up  under  treatment.      More  than  one  joint  may  be  affected. 

Deafness  is  by  no  means  uncommon,  and  usually  appears 
between  the  ages  of  ten  and  fifteen  ;  it  is  dependent  on  changes 
in  the  internal  ear. 

Affections  of  the  teeth. — The  milk  teeth  usually  escape,  but 
may  decay  early  and  crumble  away  if  there  has  been  severe  stoma- 
titis. 

The  permanent  teeth  may  or  may  not  be  affected.     The  upper 

central  incisors  are  the  ones  showing 
characteristic  changes,  but  all  may 
be  badly  and  irregularly  developed, 
and  more  or  less  pitted  if  mercury 
has  been  injudiciously  pushed.  The 
central  incisors  are  small  and  peg- 
shaped,  being  broader  at  the  base 
Fig.  42._— Malformation  of  the  upper  can-   than  at  the  Cutting  edsje,  which  latter 

tral  incisor  teeth  in  inherited  syphilis.  .  .    °  ^ 

(Hutchinson,  Aiibutt"3^>.vw (3/" JA'^/-  crumblcs  away  m  the  centre  so  that 
"'^'^  a  crescentic  notch  is  formed,  and  the 

dentine  is  exposed  by  removal  of  the  enamel  (Fig.  42). 

Affections  of  the  eye. — Interstitial  keratitis  is  in  the  great 
majority  of  cases  due  to  inherited  syphilis,  but  is  occasionally  seen 
in  the  acquired  disease. 

It  nearly  always  begins  between  eight  and  fifteen  years  of  age, 
first  in  one  eye,  and  within  a  few  weeks  in  the  other.  In  the  early 
stages  there  may  be  some  ciUary  congestion  with  photophobia,  and 
the  disease  is  considered  as  secondary  to  inflammation  of  the  ciliary 
zone.  The  cornea  becomes  hazy,  loses  its  lustre,  and  is  eventually 
rendered  quite  opaque,  and  resembles  ground  glass.  The  change 
usually  begins  about  the  centre,  but  the  margins  are  also  affected. 
If  the  disease  is  severe  and  persistent,  leashes  of  vessels  shoot  into 
the  cornea  from  the  margin ;  this  may  be  limited  to  one  segment 
(vascular  keratitis).  Ulceration  of  the  cornea  very  easily  occurs, 
and  the  inflammation  may  extend  to  the  ciliary  body  or  to  the  iris. 
After  some  weeks  or  months  the  eye  first  aftected  begins  to  clear 
up,  and  in  the  course  of  time  (often  many  months)  th^  opacity  may 
almost  entirely  disappear,  although  the  cornea  will  never  regain  its 


jx  CONGENITAL   OR   INHERITED   SYPHILIS         207 

normal  lustre.  Under  prompt  and  efficient  treatment  the  prognosis 
is  usually  good. 

lyeatmcnt.  —  If  during  the  early  stages  there  is  much  photo- 
phobia, the  child  should  be  kept  in  a  dark  room  or  wear  a  shade, 
and  eserine  or  cocaine  must  be  dropped  into  the  eyes.  Constitu- 
tional treatment  is  of  course  necessary.  To  promote  absorption  a 
little  yellow  oxide  of  mercury  ointment  should  be  put  into  the  eyes 
every  day. 

Affections  of  the  viscera  are  similar  to  those  met  with  in  the 
acquired  disease.     They  only  occur  in  bad  cases. 

Prognosis. — The  more  recent  the  infection  of  the  parents,  and 
the  earlier  the  symptoms  appear  in  the  child,  the  more  grave  is  the 
prognosis.  In  some  cases  the  disease  may  give  no  trouble  after  the 
first  few  months  ;  in  others,  symptoms  recur  during  all  the  years  of 
growth,  and  lead  to  serious  consequences.  Visceral  lesions  are 
especially  grave.  During  the  early  stage  the  affection  of  the  nasal 
and  respiratory  mucous  membrane  not  only  enfeebles  the  general 
health,  but  lays  the  child  open  to  bronchitic  and  pulmonary 
mischief. 

Syphilitic  children  are  less  able  to  combat  the  ordinary  maladies 
of  childhood  than  are  healthy  ones. 

Treatment. — The  early  lesions  of  inherited  syphilis  are  con- 
tagious, and  every  care  must  be  taken  that  the  child  does  not 
inoculate  its  attendants.  The  mother,  who  is  immune,  should  nurse 
her  own  child ;  if  she  is  unable  to  do  so,  it  must  be  brought  up  by 
hand,  and  on  no  account  should  a  wet  nurse  be  employed.  Syphilitic 
infants  require  the  utmost  care  and  attention ;  they  must  be  care- 
fully fed,  properly  clothed,  and  prevented  from  catching  cold.  No 
special  dietary  is  indicated,  but  some  advise  the  use  of  goats'  or 
asses*  milk  in  preference  to  that  of  the  cow. 

Cod-liver  oil,  maltine,  and  the  syrup  of  the  phosphate  or  iodide  of 
iron  are  advisable,  if  they  can  be  taken  without  causing  gastric  disturb- 
ance. Mercury  is  to  be  administered  by  the  mouth  or  by  inunction  ; 
the  latter  method  is  the  most  convenient,  and  is  less  liable  to  induce 
intestinal  trouble.  The  child  should  have  a  warm  bath  in  front  of 
a  fire ;  when  thoroughly  dry,  a  piece  of  linen  spread  with  about  half 
a  drachm  of  mercurial  ointment  (which  may  be  m.ixed  with  an  equal 
quantity  of  lanolin)  is  placed  over  the  abdomen  or  round  one  of  the 
thighs,  and  retained  in  position  by  a  flannel  roller.  The  seat  of 
inunction  should  be  frequently  changed,  so  as  to  avoid  irritation  of 
the  skin.  Care  must  be  taken  that  sahvation  is  not  produced,  and 
the  inunction  should  be  occasionally  remitted. 


2o8  MANUAL  OF  SURGERY  chap. 

If  mercury  is  to  be  given  by  the  mouth,  half  a  grain  of  gray 
powder,  with  a  httle  sugar,  should  be  given  thrice  daily,  and  the 
dose  may  be  increased  or  diminished  according  to  the  effects  pro- 
duced. Constitutional  treatment,  with  intervals  of  rest,  should  be 
maintained  for  at  least  six  months,  and  longer  if  the  symptoms 
indicate  it. 

Ulcerations  about  the  nasal  and  buccal  mucous  surfaces  should 
be  kept  clean ;  all  crusts  should  be  removed  from  the  nose,  and  the 
discharge  cleared  away  with  a  camel's-hair  brush ;  the  surface  may 
then  be  painted  with  a  weak  solution  of  the  perchloride  of  mercury 
with  borax.  Mucous  tubercles  about  the  genitals,  anus,  etc.  must 
be  kept  clean  and  dry,  and  dusted  with  calomel  and  starch  powder. 

The  iodides  of  potassium,  sodium,  and  ammonia  are  useful,  in 
combination  with  mercury,  in  the  later  stages,  and  may  sometimes 
be  used  with  advantage  should  the  earlier  symptoms  prove  resistant 
to  mercury  alone. 

Disease  of  the  bones  leading  to  caries  or  necrosis  will  require 
local  surgical  treatment  in  addition  to  the  constitutional. 

SOFT  CHANCRE  OR  CHANCROID 

Etiolo^. — Soft  chancre  is  a  highly  contagious,  local,  venereal 
ulcer,  never  leading  to  general  infection  of  the  blood,  but  often 
accompanied  by  bubo.  One  attack  does  not  confer  immunity 
against  others.  Chancroid  is  due  to  Ducrey's  bacillus,  which  is  small 
and  short,  with  rounded  ends,  and  stains  deeply  with  gentian-violet, 
but  not  by  Gram's  method ;  the  central  portion  of  the  bacillus 
remains  clear.  This  bacillus  is  often  arranged  in  chains.  It  has 
not  yet  been  cultivated,  but  experimental  inoculation  practically 
proves  its  specific  qualities.  It  is  not  met  with  in  any  other  form 
of  ulceration,  although  other  organisms — especially  the  ordinary 
pyogenic  varieties — are  present  with  it  in  soft  sores.  The  organism 
is  very  virulent,  but  is  destroyed  by  drying ;  it  gains  entrance 
through  abrasions  of  the  skin  or  mucous  membrane,  but  does  not 
produce  any  ill  effects  on  these  when  uninjured.  Ducrey's  bacillus 
is  sometimes  found  in  the  pus  of  the  bubo  accompanying  soft 
chancre ;  in  such  cases  the  pus,  if  inoculated,  is  capable  of  pro- 
ducing a  typical  soft  sore ;  in  most  cases,  however,  the  suppuration 
is  due  to  the  pyogenic  organisms  associated  with  soft  chancre,  and 
is  then  not  capable  of  producing  a  chancre,  nor  does  the  bubo  show 
such  virulent,  inflammatory,  and  destructive  tendencies.  It  is  prob- 
able that  in  the  case  of  acute  or  chronic  inflammation  of  the  glands 


IX  SOFT  CHANCRE   OR   CHANCROID  209 

without  suppuration,  the  process  is  due  to  absorption  of  the  toxines 
of  the  organisms  by  the  lymphatics,  rather  than  to  the  spread  of  the 
microbes  themselves. 

Direct  inoculation  during  sexual  intercourse  is  the  rule,  but 
mediate  contagion  by  fingers,  towels,  etc.  may  occur.  Auto-inocu- 
lation is  not  uncommon,  and  is  usually  due  to  scratching. 

Situation  of  the  sores. — Soft  chancres  are  nearly  always 
multiple,  and  are  situated  on  the  genitals.  In  men,  the  furrow 
behind  the  glans  penis,  especially  near  the  frenum,  is  the  most 
usual  seat  of  the  lesions ;  sometimes  they  are  scattered  over  the 
glans,  and  there  is  much  associated  balano-posthitis,  especially  in 
those  of  uncleanly  habits. 

The  skin  of  the  penis  and  scrotum  is  rarely  affected,  but  if  the 
prepuce  is  long  and  tight,  so  as  to  be  liable  to  Assuring  during 
intercourse,  numerous  soft  chancres  may  be  present  at  its  free 
margin.  In  women,  the  entrance  to  the  vagina,  the  fourchette,  and 
the  mucous  surface  of  the  labia  are  the  favourite  seats ;  the  vagina 
higher  up  is  rarely  affected.  Sometimes  soft  chancres  are  present 
round  the  anus,  either  from  auto-inoculation  or  from  unnatural 
intercourse  ;  the  latter  mode  of  infection  may  be  suspected  when 
the  sores  are  placed  close  to  and  immediately  round  the  anus. 

Clinical  characters  of  chancroid.  —  Chancroid  has  no 
appreciable  period  of  incubation,  the  pathological  process  begin- 
ning immediately  after  inoculation,  as  has  been  demonstrated  by 
numerous  experimental  inoculations.  The  patient's  attention  may 
not,  however,  be  drawn  to  the  sores  for  a  few  days,  especially  in  the 
case  of  women.  At  the  seat  of  inoculation  a  small  red  pimple, 
surrounded  by  a  narrow  zone  of  acute  inflammation,  makes  its 
appearance.  Suppuration  ensues  within  forty-eight  hours,  and  a 
pustule,  seated  on  a  red  inflamed  base,  results ;  the  pustule  bursts, 
leaving  a  characteristic  ulcer. 

The  ulcer  is  shallow  and  clean  cut,  as  if.  punched  out ;  its  base 
is  spongy,  and  covered  with  a  greenish-yellow  purulent  exudation, 
but  there  is  no  induration  unless  the  sore  has  been  irritated.  Such 
a  sore  is  very  painful,  and  is  usually  quite  small  unless  adjacent 
ulcers  have  fused,  or  inflammation  has  been  excited. 

The  ulcerative  process  usually  extends  for  a  few  days,  and 
numerous  sores  may  be  present ;  when  spreading  has  ceased  the 
ulcers  remain  stationary  for  some  days,  and  then  granulate,  healing 
being  complete  in  from  three  to  four  weeks  from  the  onset ;  the  site 
of  the  sore  is  then  indicated  by  a  small  scar. 

Complications. — Inflammation. — If  irritated  by  neglect  or  dirt, 
VOL.  I  p 


2IO  MANUAL   OF  SURGERY  chap. 

or  by  injudicious  treatment,  soft  sores  may  become  acutely  inflamed, 
and  the  ulceration  may  spread  rapidly  and  suppurate  freely.  In 
such  cases  inflammatory  induration  may  occur  at  the  base,  so  that 
the  ulcer  simulates  a  hard  chancre,  but  the  induration  is  not  so 
dense  nor  is  it  so  distinctly  circumscribed ;  moreover,  in  the 
case  of  hard  chancre,  pain  and  acute  inflammatory  signs  are 
absent. 

Balano-posthitis  is  by  no  means  uncommon,  especially  if  the 
prepuce  is  long  and  tight,  and  the  patient  regardless  of  personal 
cleanliness.  When  present,  it  causes  acute  inflammatory  phimosis, 
with  much  cedema  and  profuse  discharge,  and  may  even  result  in 
gangrene  of  the  prepuce. 

Phagedsena  may  attack  soft  sores,  especially  if  they  are  con- 
cealed beneath  a  tight  prepuce. 

Bubo. — Soft  chancre  shows  a  marked  tendency  to  involve  the 
lymphatic  vessels  and  neighbouring  glands,  which  frequently  suppu- 
rate— more  often,  however,  in  micn  than  women.  Sometimes  the 
glands  escape  completely ;  in  other  cases  they  inflame  but  do  not 
suppurate,  or  the  acute  inflammation  may  subside,  leaving  the  glands 
chronically  enlarged,  and  slow  suppuration  follows.  In  the  last  class 
of  cases,  the  sore,  having  completely  healed,  may  remain  undetected, 
and  this  has  led  some  to  think  that  the  venereal  poison  may  be 
absorbed  by  the  lymphatics  and  conveyed  to  the  glands  without  any 
local  lesion  occurring  at  the  point  of  inoculation  {biibon  d'emblee). 
There  is  no  genuine  evidence  in  support  of  this  view,  and  the  mere 
denial  of  a  sore  on  the  part  of  the  patient  will,  of  course,  be  accepted 
with  due  caution. 

The  glands  affected  are  those  along  Poupart's  ligament — the 
superficial  inguinal ;  but  in  some  cases  the  deep  glands  in  Scarpa's 
triangle  are  implicated,  and  in  one  case  under  my  care  those  along 
the  external  ihac  artery  suppurated.  Both  sides  are  often  affected, 
especially  if  the  sores  are  near  the  frenum. 

The  glandular  involvement  usually  begins  about  the  end  of  the 
second  week,  but  may  be  earlier  or  later.  The  affected  glands  are 
swollen  and  acutely  tender,  and  when  suppuration  occurs  the  cellular 
tissue  and  skin  become  oedematous,  and  the  latter  is  red  and  thinned 
as  the  pus  approaches  the  surface.  Unless  the  abscess  cavity  be 
freely  sharp-spooned,  the  destructive  process  may  continue  to  spread 
and  large  areas  of  tissue  be  destroyed ;  sinuses  may  burrow  a  long 
way,  and  the  patient  may  be  placed  in  considerable  danger  if  the 
femoral  trunk  or  its  branches  are  encroached  upon,  as  secondary 
haemorrhage  may  ensue. 


IX  SOFT  CHANCRE  OR   CHANCROID  211 

When  the  glands  inflame,  constitutional  symptoms  with  slight 
fever  may  occur,  and  are  considerably  aggravated  with  the  advent 
of  suppuration. 

Diagnosis.  —  Soft  chancre  may  be  distinguished  from  hard 
by  the  absence  of  an  incubative  stage  and  of  induration,  by  the 
multiplicity  of  the  lesions  and  the  evident  ulceration  accompanied 
by  pain,  by  the  acute  lymphadenitis  frequently  terminating  in  sup- 
puration, and  by  the  absence  of  succeeding  secondary  symptoms. 
An  inflamed  soft  chancre  only  superficially  resembles  a  hard  one, 
and  a  little  care  will  usually  avoid  any  mistake.  It  must,  however, 
be  remembered  that  a  soft  chancre  may  also  be  inoculated  with 
the  poison  of  syphilis,  and  will  then  indurate  when  the  incubative 
stage  of  that  disease  has  expired  (mixed  chancre). 

Herpes  usually  appears  as  a  crop  of  vesicles  accompanied  by 
considerable  itching  and  irritation,  but  no  pain  or  glandular  enlarge- 
ment. The  vesicles  dry  up,  and  do  not  usually  ulcerate  if  they  are 
kept  clean  and  dry.      Repeated  attacks  are  common. 

Treatment. — If  there  is  phimosis,  the  prepuce  should  be  slit 
up  so  that  the  sores  may  be  fully  exposed.  Circumcision  may  be 
performed  at  once,  provided  the  sores  are  so  situated  that  the  raw 
surface  can  be  protected  against  inoculation ;  if  this  cannot  be 
done,  or  if  there  is  inflammatory  phimosis,  the  operation  had  better 
be  postponed  until  the  morbid  process  is  cured. 

The  parts  must  be  kept  clean  by  washing  and  bathing  with 
boracic  acid  lotion  (gr.  4  ad  5i.),  the  glans  should  then  be  dried 
carefully,  and  the  sores  lightly  dusted  with  crystals  of  iodoform,  the 
unpleasant  smell  being  minimised  by  the  admixture  of  coumarine  or 
coffee.  The  dressing  should  be  repeated  at  least  twice  daily,  and 
if  the  sores  are  so  situated  that  auto-inoculation  is  likely  to  occur, 
they  should  be  covered  with  a  small  piece  of  boracic  lint.  Iodo- 
form does  not  invariably  efl'ect  healing,  and  when  it  fails  black-wash 
or  calomel  may  be  substituted. 

Some  surgeons  prefer  to  destroy  the  ulcer  at  once  with  caustic, 
in  the  hope  of  averting  glandular  abscess.  This  may  be  done,  after 
thoroughly  drying  the  parts,  by  touching  the  ulcers  with  pure  carbolic 
acid,  sulphate  of  copper,  nitric  acid,  nitrate  of  silver,  or  by  applying 
Ricord's  paste,  which  is  composed  of  strong  sulphuric  acid  and 
willow-charcoal  and  will  be  found  extremely  useful.  The  pain  caused 
by  these  applications  may  be  minimised  by  the  previous  use  of  a 
20  per  cent  solution  of  cocaine. 

If  phagedaena  occurs,  the  treatment  must  be  prompt  and  radical 
(see  p.  118). 


212  MANUAL  OF   SURGERY  chap,  ix 

As  soon  as  the  ulcers  begin  to  heal,  a  simple  unirritating  dress- 
ing, such  as  boracic  acid  lotion,  is  all  that  is  needed. 

Treatment  of  bubo. — As  soon  as  glandular  inflammation  is  pre- 
sent, the  patient  must  be  kept  quiet  to  prevent  additional  irritation. 
The  bowels  should  be  opened  and  kept  acting.  Hot  fomentations 
and  extract  of  belladonna  with  glycerine  may  prevent  suppuration, 
or  will  hasten  the  process  if  imminent.  When  an  abscess  has  formed, 
it  should  be  freely  opened  by  an  incision  passing  obliquely  across 
Poupart's  ligament  in  a  direction  downwards  and  inwards.  All  the 
diseased  gland  should  be  removed  with  the  sharp-spoon,  and  the 
resulting  wound  must  be  thoroughly  cleaned  with  1-20  carbolic  acid 
solution  and  dusted  with  iodoform.  A  piece  of  gauze  should  then  be 
placed  between  the  edges  of  the  wound,  and  a  dry  dressing  appHed  ; 
this  may  be  left  untouched  for  four  or  five  days,  when  the  wound 
will  be  found  to  be  granulating  healthily.  If,  however,  there  is  much 
surrounding  inflammation,  hot  boracic  fomentations  are  more  appro- 
priate. If  chronically  inflamed  glands  break  down,  the  whole  mass 
is  best  dissected  cleanly  away.  The  resulting  wound  will  usually 
heal  rapidly  by  first  intention. 


CHAPTER  X 

Surgical  Infective  Diseases  {Co?tti?iued) 

The  General  Infective  Diseases 

By  a  general  infective  disease  we  mean  one  that  is  dependent 
on  the  invasion  of  organisms  which  gain  entrance  to  the  blood- 
stream either  directly  through  the  veins  or  indirectly  through  the 
lymphatics.  The  organisms  are  capable  of  multiplying  in  the 
body  generally,  and  therefore  of  producing  symptoms  out  of  all 
proportion  to  the  amount  of  the  original  dose.  Pathogenic  organ- 
isms which  have  gained  entrance  into  the  blood  may  pass  into  the 
tissues. 

The  acuteness  and  severity  of  any  general  infective  disease  vary 
with  the  organism  causing  it.  Some  of  them,  e.g.  septic  infection, 
are  rapidly  induced,  and  run  an  acute  course  with  a  usually 
fatal  termination  ;  others,  such  as  syphiHs,  run  a  chronic  course, 
and  are  amenable  to  treatment.  A  third  group,  e.g.  tubercle 
and  anthrax,  may  remain  quite  local  for  a  longer  or  shorter  period, 
and  general  infection  may  be  prevented  by  timely  and  radical  treat- 
ment ;  but  if  the  local  lesions  are  neglected,  such  general  infection 
— at  any  rate  in  the  case  of  anthrax — will  certainly  ensue.  In  some 
instances  an  organism,  which  usually  only  induces  a  local  infective 
process,  may  enter  the  blood-stream  and  cause  general  infection  ; 
thus,  the  gonococcus  may  excite  gonorrhceal  rheumatism  and  be 
found  in  the  synovial  exudation,  and,  according  to  some,  the 
streptococcus  erysipelatis  may  behave  in  the  same  way  (see 
p.  123). 

Inoculation  with  a  general  infective  disease  occurs  through  a 
wound ;  but,  as  in  the  case  of  the  local  infective  diseases,  the 
mere   presence    of  the  organism   does   not    necessarily  entail  the 


2  14  MANUAL   OF   SURGERY  chap. 

establishment  of  the  disease,  certain  favouring  causes  being  essential. 
Thus  in  the  case  of  acute  necrosis  (a  form  of  septic  infection  or 
pyaemia)  it  has  been  shown  that  if  the  staphylococcus  pyogenes 
aureus  be  injected  into  the  veins  of  healthy  rabbits,  the  condition 
is  only  produced  when  a  bone  has  been  injured,  and  hence  a  weak 
spot  formed  where  the  organism  can  gain  the  upper  hand. 


ACUTE    SEPTIC    INFECTION    AND    "  PYEMIA 

Etiolo^. — Septic  infection  and  pyaemia  are  clinical  terms  im- 
plying an  assemblage  of  pathological  and  resulting  clinical  features, 
due  to  the  action  of  micro-organisms  capable  of  multiplying  in  the 
blood  and  tissues. 

These  two  states  are  regarded  by  many  as  being  distinct,  but  in 
reality  it  appears  that  so-called  pyemia  is  merely  septic  infection 
accompanied  by  the  formation  of  secondary  centres  of  suppuration, 
v,'hich  are  due,  not  to  any  inherent  difference  in  the  organisms  pre- 
sent, but  to  the  longer  duration  of  their  action,  or  to  the  more 
favourable  conditions  under  which  this  occurs. 

The  ordinary  pyogenic  organisms  are  those  most  commonly  met 
with  in  septic  infection  and  pyaemia,  the  most  virulent  and  com- 
monest being  the  streptococcus  pyogenes  and  staphylococcus  pyo- 
genes aureus  and  albus  (Figs.  9  and  10,  pp.  40,  41).  Any  of  these 
may  be  present  alone ;  but  mixed  infection  is  common,  and  seems 
to  act  more  virulently. 

The  general  causes  favouring  the  development  of  septic  infec- 
tion have  been  already  mentioned  (p.  104). 

The  disease  can,  and  ought  to  be,  prevented.  Its  occurrence  in 
accidental  or  surgical  wounds  points  to  some  imperfection  in  the 
antiseptic  method  employed.  Foul,  ill-drained  wounds  with  small 
external  openings,  and  those  implicating  the  medullary  cavities  of 
bones,  joints,  veins,  and  serous  cavities,  offer  every  facility  for  the 
absorption  of  the  virus  and  general  infection. 

A  pyasmic  process  may  occur  independently  of  any  wound,  e.g. 
ulcerative  endocarditis  and  acute  necrosis,  absorption  taking  place 
through  the  digestive  or  respiratory  mucous  tracts.  No  doubt  many 
of  us  are  thus  subjected  to  the  invasion  of  organisms  capable  of 
producing  the  most  serious  results ;  that  they  do  not  invariably  do 
so  is  dependent  on  the  resisting  powers  of  the  healthy  body,  but 
should  this  be  diminished  infection  will  occur.  Septic  infection 
and  pyaemia  may  be  acute  or  chronic. 


X  ACUTE   SEPTIC   INFECTION  215 

ACUTE    SEPTIC    INFECTION    (SEPTICEMIA) 

Symptoms. — The  symptoms  of  acute  septic  infection  are 
similar  to,  but  more  severe  than,  those  met  with  in  acute  septic 
intoxication  (p.  106).  The  onset  is  sudden  and  ushered  in  by  a 
severe  rigor,  and  the  temperature  rises  to  104"  or  105'  F.,  with 
nocturnal  exacerbations.  Headache,  nausea,  and  vomiting  are 
constant,  and  diarrhcea  is  by  no  means  an  uncommon  symptom. 
The  rigor  and  profuse  sweating  weaken  the  patient,  and  nervous 
prostration  is  rapidly  induced.  The  pulse  is  rapid,  and  soon 
becomes  feeble  and  perhaps  irregular.  The  respirations  are  hurried 
and  shallow,  the  skin  hot  and  dry,  but  towards  the  end  is  covered 
with  a  profuse,  clammy  sweat.  The  urine  may  contain  albumen. 
Delirium  at  night  is  the  rule ;  and  as  the  nervous  prostration 
becomes  more  profound,  and  typhoidal  symptoms  show  themselves, 
it  deepens  into  coma  before  death.  Any  wound  which  may  be 
present  ceases  to  heal,  and  may  inflame.  The  discharges  are  putrid 
and  offensive. 

Death  usually  occurs  within  a  week  from  the  onset,  and  is  often 
preceded  by  purpuric  spots  about  the  body. 

DiagTlosis.  —  Septic  infection  may  be  mistaken  for  septic 
intoxication.  In  the  former  state,  the  greater  severity  of  the 
symptoms,  and  the  fact  that  they  continue  after  all  putrefying 
material  has  been  removed  from  the  wound,  are  the  diagnostic 
features. 

Post-mortem  appearances  (see  p.  218). 

Treatment  is  of  little  avail,  the  great  majority  of  cases  proving 
rapidly  fatal.  The  wound  must  be  thoroughly  disinfected  and 
drained.  The  general  treatment  consists  in  the  plentiful  adminis- 
tration of  good,  nutritious  fluid  food,  with  free  alcoholic  stimulation. 
Bark,  quinine,  and  ammonia,  with  digitalis  or  strychnine,  if  the 
heart  fails,  are  the  most  useful  drugs.  If  the  temperature  runs 
very  high  large  doses  of  quinine  or  antipyrin,  or  cold  packing  may 
be  resorted  to.  The  action  of  the  kidneys  and  bowels  must  be 
promoted. 

Anti-streptoeoeeus  serum  is  employed  in  cases  of  infection  by 
streptococci.  At  present  its  therapeutic  value  is  undetermined,  for 
in  some  cases  it  is  apparently  very  beneficial,  while  others  remain  i?i 
statu  quo  ;  it  may  be  generally  stated  that  the  remedy  if  it  does  no 
good  will  not  be  productive  of  harm.  It  should  be  used  as  soon  as 
the  symptoms  are  manifestly  due  to  streptococcus  infection,  and 
the  dose  (10  c.cm.)  should  be  repeated  about  every  six  hours.     In 


2i6  MANUAL  OF   SURGERY  chap. 

successful   cases  the  temperature   falls,  and  the  local  and  general 
symptoms  rapidly  improve. 

CHRONIC    SEPTIC    INFECTION 

The  chronic  disease  is  more  likely  to  occur  in  those  who  are 
broken  down  by  some  old-standing  disease.  The  symptoms  are 
the  same  in  kind,  but  differ  in  severity  from  those  met  with  in  the 
acute  form.  Rapid  anaemia  and  emaciation  are  produced,  and  the 
spleen  is  always  enlarged.  Death  occurs  in  about  half  the  cases, 
but  the  course  of  the  disease  may  extend  over  weeks  or  months. 
The  treatment  is  similar  to  that  of  acute  septic  infection. 

ACUTE    SEPTIC    INFECTION    WITH    SECONDARY    ABSCESSES    (tYJESHa) 

The  general  course  of  pyaemia  precisely  resembles  that  of  septic 
infection,  and  the  constitutional  symptoms  are  similar,  though 
perhaps  even  more  severe  ;  but  there  are  in  addition  signs  and 
symptoms  dependent  on  the  establishment  of  secondary  suppura- 
tive foci. 

Symptoms. — Pycemia  is  ushered  in  by  a  very  severe  rigor, 
which  commences  a  few  minutes  after  the  temperature  begins  to  rise. 
During  this  rigor  the  Hps  are  blue  and  cyanosed,  and  the  surface  of 
the  skin  is  pale  and  cold  ;  the  temperature  reaches  105"-!  06'  F.  As 
the  cold  stage  passes  off  the  skin  is  suffused  with  blood,  and  the 
patient  is  bathed  in  profuse  perspiration  ;  the  temperature  falls, 
and  he  is  left  very  much  weakened.  In  the  great  majority  of  cases 
the  rigor  is  repeated  within  twenty-four  hours,  and  many  others 
may  follow.  Each  rigor  is  marked  by  a  fresh  elevation  of  tempera- 
ture, which  again  falls  during  the  sweating  stage,  only  to  be  suc- 
ceeded by  another  elevation.  The  wide  fluctuations  of  temperature 
within  a  short  space  of  time  are  very  characteristic  of  the  disease, 
and  although  the  temperature  may  fall  to  the  normal  or  even  below 
it,  it  never  remains  low.  Between  the  rigors,  when  the  sweating 
has  subsided,  the  skin  is  hot  and  pungent,  and,  as  the  disease  pro- 
gresses, assumes  an  icteric,  sallow  tint,  with  evanescent  patches  of 
erythema.  The  expression  is  anxious,  careworn,  and  apprehensive; 
the  eyes  are  bright,  or  may  be  leaden  and  surrounded  by  dark 
rings.  The  cheeks  are  pale  or  flushed,  especially  the  latter  if  the 
lungs  are  implicated  by  secondary  inflammation.  Herpetic  patches 
may  appear  about  the  mouth  or  al^  of  the  nose. 

Respiration  is  hurried  and  shallow,  and  may  be  very  rapid  or 


ACUTE  SEPTIC  INFECTION 


217 


impeded  if  pneumonia  or  empyema  is  present.  The  breath  has  a 
peculiar  sickly-sweet  smell.  The  lips  and  teeth  are  loaded  with 
sordes,  the  tongue  is  dry,  brown,  and  cracked,  the  mouth  clammy ; 
thick,  tenacious  mucus  hangs  about  the  throat  and  fauces,  some- 
times occasioning  the  patient  much  annoyance.  Anorexia,  thirst, 
and  nausea  are  present.  The  bowels  may  be  confined,  or  profuse 
diarrhoea  may  further  increase  the  prostration.  The  urine  is  scanty, 
high  coloured,  and  probably  albuminous.  Cardiac  failure  and 
nervous  prostration  are  marked.  At  first  there  is  headache  during 
the  day,  which  disappears  as  nocturnal  delirium  comes  on  ;  later  on, 
delirium  of  a  low,  busy,  muttering  nature  is  constant  {typhoma?iia). 

Emaciation  and  anaemia  are  rapidly  produced,  and  towards  the 
end  the  patient  falls  into  the  typhoid  state.  He  is  lethargic  and 
profoundly  indifferent  to  all  around  him,  delirium  and  coma  may 
alternate  ;  risus  sardonicus,  floccitatio,  subsultus  tendinum,  and  pro- 
fuse diarrhoea,  with  involuntary  evacuations  of  an  offensive  nature, 
usher  in  the  end. 

The  secondary  abscesses  may  not  produce  any  definite 
symptoms,  either  because  they  are  so  small,  or  because  of  their 
situation  in  unimportant  parts,  or,  again,  because  the  condition  of 
the  patient  is  so  grave  that  he  does  not  show  any  evidence  of  their 
presence. 

The  abscesses,  which  are  due  to  the  lodgment  of  infective 
emboli,  usually  appear  about  five  days 
from  the  onset  of  the  disease.  No  organ 
or  tissue  of  the  body  is  exempt,  but  cer- 
tain parts  are  more  particularly  affected ; 
the  joints,  subcutaneous  tissue,  lungs, 
liver,  kidneys,  and  spleen  are  the  principal 
seats  of  secondary  inflammation  and  sup- 
puration. The  occurrence  of  inflamma- 
tion may  be  marked  by  pain  and  swelling 
of  the  part,  or  by  some  symptom  referable 

to     the    visCUS    involved.         Of    the    joints,     Fig.  43.  — Colonies  of  micrococci 

the  knee  is  the  one  most  usually  afl-ected,  Jzk^^L?'  ^'^'''''  capillaries 
but  others  are   rapidly   attacked ;    if  the 

patient  survives  long  enough,  suppuration  ensues,  and  numerous 
sinuses  may  form.  Subcutaneous  abscesses  or  diffuse  patches  of 
cellulitis,  which  may  or  may  not  suppurate,  are  common. 

The  serous  membranes  are  not  infrequently  affected ;  as  a  rule, 
their  implication  is  secondary  to  \-isceral  lesions,  but  is  not  necessarily 
so.     The  formation  of  pyemic  abscesses  is  remarkably  rapid ;  they 


2i8  MANUAL   OF  SURGERY  chap. 

may  be  very  numerous  and  never  attain  a  large  size.  They  con- 
tain an  oily,  watery,  and  greasy  pus. 

Diagnosis. — The  chief  diagnostic  features  are  the  repeated  and 
severe  rigors  and  characteristic  fluctuations  of  temperature  occurring 
in  a  patient  with  a  foul  wound.  Later  on,  the  secondary  inflamma- 
tions and  abscesses  and  the  rapid  downward  progress  of  the  case 
render  the  diagnosis  certain. 

The  joint  lesions  in  acute  rheumatic  fever  make  their  appear- 
ance earlier,  and  do  not  lead  to  suppuration ;  moreover,  the 
repeated  rigors  are  absent,  and  the  temperature  remains  con- 
tinuously high.  In  acute  rheumatism  there  is  a  characteristic  sour 
smell  in  contradistinction  to  the  sickly,  earthy  smell  of  pyaemia; 
moreover,  the  tongue  is  covered  with  a  thick,  creamy  fur  in  the 
former  condition,  and  is  dry  and  brown  in  the  latter.  Attacks  of 
ague  are  marked  by  distinct  periodicity,  the  patient  being  perfectly 
well  during  the  intervals  ;  there  are  no  secondary  lesions. 

Prognosis. — Acute  pyaemia  is  almost  always  fatal  in  from 
four  to  ten  days. 

Post-mortem  appearances  of  septic  infection  and 
pyasmia. — These  are  similar  to  those  met  with  in  sapraemia  and 
septic  diseases  generally.  In  pyemia  there  are  the  secondary 
abscesses. 

Post-mortem  decomposition  sets  in  early  and  proceeds  rapidly, 
so  that  the  whole  body  speedily  swells  from  gaseous  accumulation, 
and  may  be  almost  unrecognisable.  There  is  marked  staining  of 
the  dependent  parts  and  tissues  generally,  and  the  surface  veins 
are  clearly  mapped  out.  The  various  organs  are  congested  and 
cedematous,  and  may  be  inflamed.  In  pyaemia  infarcts  and  em- 
bolic abscesses  are  common.  The  spleen  is  enlarged,  soft,  and 
may  be  diffluent.  The  serous  cavities  contain  an  increased 
quantity  of  fluid,  which  is  turbid  and  blood-stained.  Petechial 
patches  and  purulent  collections  are  common.  The  wound 
will  be  found  to  be  in  a  sloughy  condition  ;  the  veins  leading 
from  it  are  acutely  inflamed  and  plugged  with  breaking-down 
thrombi,  which  are  loaded  with  micro-organisms.  During  life 
these  thrombi  disintegrate  and  break  down,  giving  rise  to  emboli 
charged  with  the  infective  agent.  Such  emboli,  being  carried  to 
distant  organs  and  tissues,  excite  in  them  at  their  points  of  lodgment 
the  secondary  abscesses,  and  thus  additional  phlebitis  and  throm- 
bosis are  occasioned,  and  the  process  is  repeated  indefinitely.  The 
walls  of  a  pyaemic  abscess  are  often  sloughy  and  ill-defined  on 
account  of  the  rapidity  of  its  formation  and  the  highly  irritating 


X  EQUINIA  OR   GLANDERS— FARCY  219 

nature  of  its  cause ;  inflammation  often  extends  a  long  distance 
round. 

Micro-organisms  are  found  in  all  the  tissues  and  organs,  in  the 
vessels  and  lymphatics,  and  in  the  purulent  collections  and  other 
fluids. 

Treatment. — The  treatment  of  acute  pyaemia  is  conducted  on 
the  same  lines  as  for  septic  infection.  Secondary  abscesses  should 
be  opened  and  disinfected,  provided  their  situation  admits  of  such 
a  procedure.  In  some  cases  general  infection  may  be  prevented 
by  ligaturing  a  thrombosed  vein  leading  from  the  seat  of  inocula- 
tion (see  Otitis  Media,  chap.  xi.  vol.  iii.). 

CHRONIC    PYEMIA 

Chronic  pyaemia  may  extend  over  many  months  and  terminate 
in  death  or  recovery.  The  symptoms  are  similar  to,  but  less 
severe  than,  those  of  the  acute  disease.  Abscesses  form  in  the 
joints  and  subcutaneous  tissues,  but  the  vital  organs  are  not 
affected,  otherwise  death  would  speedily  ensue.  Abscess  after 
abscess  may  form,  inflicting  much  suffering  and  ultimate  damage. 
Emaciation  and  anaemia  are  very  marked.  The  treatment  is  the 
same  as  for  the  acute  disease. 


EQUINIA    OR    GLANDERS — FARCY 

Etiology. — Glanders  is  a  common  disease  among  horses,  asses, 
and  mules,  and  may  be  communicated  by  them  to  man,  but  in  spite 
of  its  highly  contagious  nature  such  com- 
munication is  rare.      Infection  may  occur         "^     "^^  "^ 


through    the    mucous    membrane    of    the 


nose  and  upper  respiratory  tract  or  through  ^^^   ^  ^-     % 

a  wound ;  in  the  former  case  it  is  probable  «,  ^            ^ 

that  in  most  if  not  all  instances  a  small  ^^ 

scratch  or  abrasion  is  present.      Glanders  Fig.  44--Bacnius  mallei  (gkn- 

..     ,  .    .  ders)  and  red  blood  cells. 

IS  the  term  usually  applied  to  acute  equmia, 

the  chronic  forms  being  known  as  farcy,  but  there  is  no  real  difference 

in  the  morbid  processes.      The  bacillus  fnallel  has  been  proved  to 

be  the  infective  agent.       It  resembles  the  B.   tuberculosis,   but  is 

broader,  motile,   and  stains  differently.      It  is  abundantly  present 

in  the  farcy  buds,  abscesses,  nasal  discharge,  and  in  the  blood  and 

lymph. 

Signs  and  symptoms. — The  acute  form  of  glanders  is  that 


220 


MANUAL  OF   SURGERY 


CHAP, 


most  common  in  man,  and  symptoms  make  their  appearance 
within  fourteen  days  of  inoculation,  and  may  apparently  arise  at 
any  date  during  that  period. 

The  leading  characters  of  glanders  are  the  formation  of  papules 
and  nodules  in  the  skin,  mucous  membrane  of  the  nose,  lungs,  etc., 
and  the  formation  of  deep-seated  abscesses ;  the  lymphatics  are 
inflamed  and  the  glands  enlarged,  especially  in  chronic  cases,  and 
general  infective  poisoning  terminates  the  case.  The  onset  may  be 
gradual  and  marked  by  lassitude  and  malaise,  with  general  pains 
of  a  rheumatic  nature ;  more  rarely  a  rigor  ushers  in  high  fever  and 
the  characteristic  symptoms. 

The  wound,  if  there  be  one,  inflames  and  the  lymphatics 
and  adjacent  glands  participate.  In  a  few  days  cutaneous  tubercles 
{farcy  buds)    make    their    appearance    and,    affecting    the    mucous 

lining  of  the  nose,  give  rise,  when 
ulceration  occurs,  to  an  offensive, 
sanious,  watery  discharge  which 
later  on  becomes  slimy  and  tena- 
cious. The  disease  may  spread  to 
the  air-sinuses.  The  tubercles  on 
the  skin  appear  in  crops  and  re- 
semble in  some  respect  the  lesions 
of  smallpox.  At  first  they  are 
vesicular  or  hard  and  shotty  papules 
situated  on  a  broad,  inflamed,  and 
indurated  base.  Softening  and 
suppuration    of    the    nodules    with 

Fig.  45.-Acute  glanders  eight  days  after  hemorrhage  into  them  soon  occurs  ; 
infection  (Tiiimans,  after  Birch-Hirsch-   the  pustulcs  break  down  and  give 

rise  to  sloughy  ulcers  which,  by 
confluence,  may  cover  considerable  areas.  Occasionally  the  vesi- 
cular lesions  do  not  suppurate  or  rupture,  but  dry  up  and  scab. 
Deep  abscesses  may  make  their  appearance  in  the  limbs,  or  sup- 
purative synovitis  may  occur,  the  patient  presenting  the  usual  signs 
of  pyaemia.  If  the  respiratory  tract  is  specially  involved,  bronchitis 
or  pneumonia  supervene. 

The  constitutional  symptoms  are  those  common  to  all  acute 
infective  processes.  The  temperature  gradually  rises,  attaining  a 
height  of  104°- 105°  F.,  and  shows  marked  fluctuations.  Con- 
stipation is  usually  present  at  first,  but  may  be  followed  by  bloody 
diarrhoea  from  involvement  of  the  intestinal  tract.  There  is  marked 
cardiac  and  nervous  depression,  and  the  patient,  soon  passing  into 


X  EQUINIA  OR   GLANDERS— FARCY  221 

the  typhoid  state,  becomes  comatose  and  dies  in  from  one  to  three 
weeks  after  the  onset.  In  the  chronic  form  {farcy')  the  signs  are 
similar  in  nature  but  less  marked,  and  gradual  recovery  or  death 
from  exhaustion  may  result. 

Diagnosis. — When  the  disease  is  fully  developed  the  diagnosis 
is  easy,  but  at  the  onset  glanders  may  be  mistaken  for  acute 
rheumatism  or  septic  infection.  The  diagnosis  rests  chiefly  on  the 
history  of  the  case  and  known  exposure  to  infection,  the  charac- 
teristic discharge  from  the  nose,  the  skin  lesions,  and  the  usually 
gradual  onset. 

In  doubtful  cases  of  glanders  among  horses,  the  diagnosis  can 
be  confirmed  by  the  injection  of  malleht — an  extract  of  pure 
cultures  of  the  bacillus.  If  the  animal  is  infected,  the  injection 
causes  a  rise  of  temperature. 

Prognosis. — Acute  glanders  is  fatal,  but  about  50  per  cent 
recover  when  the  disease  is  chronic. 

Treatment. — A  wound  which  has  probably  been  infected  should 
be  completely  excised  or  freely  cauterised.  The  treatment  of  the 
disease  consists  in  keeping  up  the  patient's  strength  with  plenty  of 
easily  digested  food  and  stimulants,  and  the  administration  of  quinine. 
Strychnia,  arsenic,  and  mercurial  inunction  are  specially  recom- 
mended by  some.  The  ulcers  must  be  treated  with  strict  asepsis, 
and  the  nasal  douche,  coupled  with  the  insufflation  of  iodoform, 
should  be  freely  used.  Great  care  must  be  taken  that  the  attendants 
are  not  inoculated  by  the  highly  contagious  discharges. 

It  has  been  suggested  to  employ  mallein  as  an  anti-toxine ;  it 
has  apparently  been  beneficial  in  chronic  cases. 


CHAPTER   XI 

Tumours  and  Cysts 

Tumours 

Definition. — A  tumour  is  a  new  growth  of  simple  or  complex 
nature,  arising  independently  of  inflammation  and  serving  no  useful 
physiological  purpose.  The  term  neoplasm  or  new  growth  is  not 
intended  to  imply  that  tumours  are  composed  of  some  tissue 
normally  foreign  to  the  body,  since  all  have  their  anatomical  proto- 
types. A  tumour  is,  in  fact,  only  a  new  growth  in  the  sense  that  the 
tissue  cells  of  which  it  is  composed  grow  in  an  atypical  and 
irregular  manner,  are  often  imperfectly  developed,  and  m.ay  be 
present  in  situations  where  they  are  not  normally  found.  More- 
over, such  new  growths  either  remain  more  or  less  distinct  from 
their  surroundings  or  gradually  infiltrate  and  invade  them,  tending 
to  progressive  increase  in  size  and  to  early  degeneration. 

A  hypertrophy  differs  from  a  tumour  in  that  its  growth  proceeds 
in  a  perfectly  regular  and  uniform  manner  in  accordance  with 
recognised  physiological  laws,  in  response  to  some  increased  need 
for  additional  development.  The  whole  organ  or  part  is  enlarged, 
and  the  overgrown  or  added  elements  fulfil  a  definite  physio- 
logical purpose,  and  do  not  degenerate  or  produce  harmful 
results. 

Inflammatory  tissue,  such  as  is  seen  forming  tumour-like  masses 
in  the  infective  granulomata  (tubercle,  syphilis,  actinomycosis,  etc.), 
differs  from  a  tumour  in  being  traceable  to  a  very  distinct  known 
cause,  and  in  its  tendency  to  undergo  absorption,  to  organise,  or  to 
break  down  and  suppurate. 

Etiology. — Very  little  is  known  as  to  the  actual  causes  leading 
to  the  growth  of  tumours ;  it  is  most  probable  that  they  are  com- 


CHAP.  XI 


TUMOURS 


223 


plex  and  variable ;  and  that  one  form  of  tumour  may  be  the  out- 
come of  factors  totally  inadequate  to  produce  another. 

Heredity. — Hereditary  tendency  to  the  growth  of  tumours  is 
evidenced  by  the  freijuent  occurrence  of  growths  of  the  same 
nature  {e.g.  fatty)  in  members  of  the  same  family,  a  tendency  some- 
times traceable  through  many  generations.  The  inherited  tendency 
is  usually  local,  that  is,  it  affects  a  special  tissue  {e.g.  the  epithelium 
in  the  case  of  cancer)  and  not  all  tissues  alike.  It  is  the  predis- 
position to  tumour  formation,  not  the  tumour  itself,  which  is 
hereditary.  While  we  all  recognise  the  influence  of  heredity  we  do 
not  thereby  explain  much ;  we  only  accord  to  tumours  what  we 
daily  recognise  as  true  of  our  physical  and  mental  qualities,  viz. 
that  a  parent  may  transmit  to  his  offspring  certain  individual  or 
local  characteristics  which  he  himself  possesses. 

Embryonic  inclusion  is  an  attractive  theory  of  the  origin  of 
tumours  promulgated  by  Cohnheim.  It  suggests  that  during 
development  certain  cellular  ele- 
ments remain  in  the  tissues  in  an 
undeveloped  state  ready,  under 
appropriate  stimulation,  to  grow 
and  multiply  and  form  a  tumour. 
These  embryonic  remains  may 
have  arisen  from  a  surplus  of  the 
cells  necessary  to  form  the  part  in 
which  they  lie,  or  by  inclusion  of 
cells  foreign  to  it  but  normal  to 
adjacent  structures,  which  have 
become  included  owing  to  the 
complexity  of  the  developmental 
processes.  No  doubt  dermoid 
and  some  other  tumours  are  due 
to  such  a  cause,  and  it  is  well 
ascertained  that  cartilaginous  areas  may  be  persistent  in  bones 
(especially  in  rickety  subjects)  and  be  the  starting-points  of 
chondromata  (Fig.  46) ;  moles  and  pigmented  spots  may  fairly  be 
considered  as  embryonic  remains,  and  we  know  that  these  are 
peculiarly  liable  to  be  the  seats  of  sarcomata.  Yet  it  is  very  doubt- 
ful at  present  what  degree  of  importance  must  be  attached  to  Cohn- 
heim's  theory  ;  for  cancers  and  some  other  growths  it  is  almost 
certainly  untrue.  Cohnheim  himself  admitted  that  the  existence 
of  embryonic  remains  cannot  be  demonstrated  in  the  majority  of 
cases ;  but  the  difficulty  of  such  demonstration  is  sufficiently  obvious. 


Fig.  46. — Condyles  and  epiphysial  line  of  a 
rickety  femur,  with  a  cartilage  island 
(Bland  Sutton). 


224  MANUAL  OF   SURGERY  -    chap. 

Assuming  the  general  correctness  of  the  theory,  no  explanation 
is  forthcoming  as  to  why  these  embryonic  cells  should  remain 
quiescent  for  many  years  and  subsequently  form  tumours,  although 
no  doubt,  whatever  the  exciting  causes  may  be,  they  all  act  by 
bringing  about  increased  nutrition  whereby  the  hitherto  dormant 
cells  are  awakened  into  activity.  Perhaps  injury  and  local 
irritation  may  become  exciting  causes  by  inducing  an  afflux  of 
blood  to  the  part.  It  may  perhaps  be  pointed  out  here  that  we 
do  not  know  v\-hy  the  beard  and  pubic  hair  should  only  begin  to 
grow  at  puberty,  since  the  hair-follicles  are  certainly  present  at 
birth. 

Origin  in  vestiges. — Tumours  may  arise  in  connection  with 
parts  of  the  body  which  were  of  use  during  development  but  are 
functionless  in  the  adult  state,  and  should  undergo  atrophy  or 
remain  quiescent.  These  are  known  as  vestiges.  Others  are  the 
remains  of  the  generative  organs  of  the  opposite  sex,  e.g.  the 
parovarium,  hydatid  of  ■Morgagni,  and  organ  of  Giraldes. 

The  linguo-hyal  duct  and  processus  ad  testem  are  instances  of 
vestiges  from  fcetal  structures.  Dermoids  and  cysts  are  commonly 
met  with  in  all  these  situations. 

Mechanical  irritation  and  injury. — An  injury,  such  as  a  blow 
or  sprain,  is  sometimes  credited  by  the  patient  with  being  the  cause 
of  a  tumour,  especially  of  the  sarcomata.  The  effect  of  such  an 
injury  is  ver}-  doubtful,  and  in  some  cases,  at  least,  it  probably 
draws  the  patient's  attention  to  the  part  which  is  already  the  seat  of 
a  new  growth,  and  it  is  hence  wrongly  described  as  the  cause  thereof. 
Long-continued  irritation  is  undoubtedly  a  causative  factor  in  the 
birth  of  some  tumours,  especially  the  epitheliomata ;  but  the 
proportion  of  cases  of  all  tumours  traceable  to  mechanical  injury, 
even  as  a  casual  relation,  is  so  small  that  its  etiological  importance 
must  still  remain  undetermined. 

It  is  noticeable  that  carcinoma  is  especially  liable  to  attack 
those  parts  of  the  body  most  subjected  to  mechanical  irritation  and 
friction.  Thus,  cancer  of  the  alimentary  tract  usually  occurs  at  the 
sides  of  the  tongue,  the  narrowest  part  of  the  oesophagus,  the 
pylorus,  ilio-Ccecal  valve,  colon,  and  rectum  ;  the  cervix  is  much 
more  commonly  affected  than  is  the  body  of  the  uterus,  and  the 
glans  penis  than  the  sheath. 

Irritated  scars  are  especially  liable  to  become  epitheliomatous. 
Incontrovertible  evidence  of  the  production  of  epithelioma  as  the 
result  of  irritation  seems  to  be  furnished  by  the  almost  complete 
disappearance  of   chimney-sweep's    cancer   of   the   scrotum   since 


XI  TUMOURS  225 

the  introduction  of  the  present  mode  of  sweeping  chimneys  and  the 
consequent  diminished  contact  witli  the  soot. 

Parasitic  origfin. — It  is  probable  that  cancers  and  sarcomata 
which  have  many  analogies  with  the  infective  granulomata,  and 
perhaps  other  tumours,  are  dependent  on  parasitic  infection ;  but 
at  the  present  time  experiments  in  inoculation  and  cultivation 
have  met  with  uniformly  negative  results. 

Bodies  resembling  Protozoa,  and  stated  to  be  such  by  some 
pathologists,  have  been  recognised  as  sometimes  occurring  in 
cancer  cells,  and  also  occasionally  in  sarcomata. 

Those  who  deny  that  these  "  cancer  bodies "  are  parasitic 
Protozoa  ascribe  the  appearances  to  endogenous  cell  formation  or  to 
degenerative  changes.  Such  bodies  have  been  fully  demonstrated 
as  occurring  in  Paget's  disease  of  the  nipple,  which  is  not  in- 
frequently accompanied  by  cancer,  and  they  have  also  been  found 
in  duct  cancer  of  the  mamma.  It  is  well  known  that  coccidia 
gaining  entrance  to  the  bile  ducts  of  the  rabbit,  and  occasionally 
of  man,  cause  cystic  dilatation  with  papillomatous  outgrowths 
from  the  wall  of  the  ducts,  closely  resembling  the  naked-eye 
appearances  of  cancer,  and  microscopically  similar  to  villous  or  duct 
cancer.  The  malignant  nature  of  cancer  and  sarcoma  and  the 
certainty  with  which  they  induce  deterioration  of  health  and 
speedy  death,  even  when  not  involving  vital  structures,  are  strong 
evidences  of  their  parasitic  origin  and  toxic  effects. 

Influence  of  age. — Tumours  may  appear  at  any  age,  but  some 
occur  with  greater  frequency  in  young  or  advanced  life  respectively. 
Sarcomata  are  more  likely  to  occur  in  young  patients ;  cancer  in 
those  past  middle  life ;  while  the  fibro-myoma  of  the  uterus  does 
not  usually  occur  after  the  menopause.  Innocent  tumours  are 
more  usually  found  during  the  first  thirty  years  of  life  than  after 
that  time,  but  this  rule  is  by  no  means  absolute. 

The  growth  of  tumours  is,  like  that  of  normal  tissue,  directly 
dependent  on  the  blood  supply,  which  is  derived  both  from  vessels 
of  new  formation  and  those  normal  to  the  part  in  which  the  tumour 
grows. 

As  already  stated,  it  Is  characteristic  of  tumour  formation  that 
the  growth  of  the  component  elements  is  irregular,  and  that  they 
are  often  imperfectly  developed  as  compared  with  their  normal 
prototypes.  This  imperfection  shows  itself — when  growth  has 
progressed  for  a  time  that  varies  in  different  tumours — by  the  often 
widespread  degenerative  changes  which  occur  in  the  unstable 
cells. 

VOL.  I  Q 


2  26  MANUAL  OF   SURGERY  chap. 

Tumours  may  increase  in  size  by  central,  general,  or  peripheral 
growth,  and  in  the  last  method  show  a  decided  tendency  to  in- 
filtrate the  surrounding  structures.  Sarcomata  and  cancers  are 
essentially  infiltrating  growths.  In  non-malignant  tumours  circum- 
scription is  the  rule,  and  the  localised  mass  is  enclosed  in  a  more 
or  less  dense  capsule  of  connective  tissue  derived  from  that  normal 
to  the  part  which  is  increased  as  the  result  of  irritation. 

Cancers  are  never  encapsuled,  sarcomata  rarely  so. 

The  actual  size  attained  by  tumours  varies  in  the  different 
forms ;  for  obvious  reasons  the  innocent  growths,  which  are  only 
mechanically  dangerous  to  life,  usually  attain  much  greater  dimen- 
sions than  do  the  malignant,  and  some  of  them,  e.g.  fibroid  and 
fatty,  may  become  enormous  and  weigh  many  pounds. 

The  size  of  innocent  tumours  is  dependent  in  some  measure 
upon  whether  the  situation  in  which  they  grow  offers  great  or  little 
mechanical  resistance  to  their  increase. 

The  rapidity  of  growth  varies  in  the  different  forms.  Innocent 
tumours  usually  grow  slowly,  malignant  ones  quickly,  although 
exceptions  to  this  general  law  are  not  uncommon ;  and  it  is 
noticeable  that  the  same  species  of  tumour  may  grow  more  quickly 
at  times  than  at  others,  although,  perhaps,  no  cause  for  such  a 
difference  may  be  evident. 

Innocent  growths  may  attain  a  certain  size  and  then  remain 
stationary,  perhaps  to  increase  again  at  some  future  time ;  or, 
having  grown  slowly  for  a  long  time,  they  may  suddenly  and 
rapidly  increase  in  a  manner  suggestive  of  the  supervention  of 
some  malignant  element.  Occasionally  innocent  tumours  undergo 
more  or  less  atrophy,  especially  if  the  normal  vascularity  of  the 
part  is  impaired  {e.g.  uterine  fibroids  at  the  menopause  or  after 
oophorectomy),  or  if  some  mechanical  cause  of  irritation  which 
induces  hyperaemia  is  removed. 

As  regards  the  rapidity  of  growth  of  malignant  tumours,  it  may 
be  generally  stated  that  this  is  usually  proportional  to  their 
vascularity  and  softness,  and  that  the  earlier  the  age  at  which  they 
appear  the  more  rapidly  do  they  grow. 

Degenerative  and  inflammatory  changes. — Tumours  are 
subject  to  all  the  pathological  processes  which  may  attack  healthy 
tissues,  and  so  common  are  degenerative  changes  that  these  may 
be  regarded  as  normal  occurrences  in  their  life-history.  As  with 
individuals,  so  with  cells,  physiological  activity  and  rapidity  of 
growth  (clinically  evidenced  in  the  case  of  tumours  by  their  soft- 
ness) entail  the  penalty  of  degeneration  and  death  earher  than  do 


XI 


TUMOURS 


227 


the  reverse  conditions ;  hence  degenerative  changes  are  more  wide- 
spread and  common  in  sarcomata  and  cancers  than  in  the  slowly- 
growing,  innocent  tumours. 

Fatty  degeneration  is 
the  most  common  form, 
but  colloid,  mucoid,  and 
pigmentary  also  occur, 
and  calcareous  and  ossi- 
fic  changes  are  often  met 
with  in  some  innocent 
growths  and  in  sarcomata 
of  the  periosteum  (Fig. 
47).  Haemorrhages  are 
common  in  soft  vascular 
tumours,  such  as  sarco- 
mata and  soft  glandular 
cancer,  the  rupture  of  the 
vessels  being  favoured  by 
degenerative  changes  in 
and  softening  of  the  tumour 
tissue,  whereby  the  vessels 
are  deprived  of  support 
and  readily  rupture  under 
the  blood-pressure  or  from 
slight  injury. 

Degenerative  changes, 
softening,  or  haemorrhage 
may  result  in  the  forma- 
tion of  definite  cysts  con- 
taining blood  with  broken- 
down,  fatty,  or  colloid  cell- 
ular elements  and  serous 
fluid. 

Inflammation  and  sup- 
puration of  the  substance 
of  a  tumour  may  occur,  but 
is  not  common.  Pedun- 
culated growths,  e.g-.  ovarian 
cysts,  may  suppurate  or  slough  if  the  circulation  through  the  pedicle 
be  sufficiently  impaired  by  torsion  or  otherwise. 

Subcutaneous   or   submucous   tumours   may,    as    the    result   of 
pressure,  so  impair  the  circulation  through  the  parts  covering  them 


Fig.  47. — Skeleton  of  an  ossifying  periosteal  sarcoma  of 
the  femur  (Bland  Sutton). 


2  28  MANUAL  OF  SURGERY  chap. 

that  inflammation  followed  by  sloughing  is  occasioned.  The 
tumour  substance  is  thus  exposed  and  may  either  form  a  fungous 
mass  on  the  surface,  or  may  itself  share  in  the  inflammatory  process, 
and  spontaneous  cure  by  sloughing  then  sometimes  results  if  the 
tumour  is  innocent. 

The  number  of  tumours. — New  growths  are  usually  single, 
but  they  may  be  multiple  and  are  sometimes  very  numerous,  e.g. 
fatty  and  fibroid  tumours. 

In  some  cases  more  than  one  kind  of  growth  is  present  at  the 
same  time. 

The  secondary  manifestations  of  malignant  growths  will  be 
subsequently  dealt  with. 

The  effects  of  tumours. — All  neoplasms  act  as  true  parasites, 
deriving  their  sustenance  from  and  at  the  expense  of  the  host,  and 
serving  no  useful  purpose  in  return. 

Innocent  growths  act  mechanically  only,  while  the  malignant 
ones  affect  the  general  health  as  well. 

Locally  a  tumour  exerts  pressure  upon,  and  occupies  the  place 
of  the  tissues  normal  to  the  part,  which  consequently  become 
atrophied  and  altered  in  shape ;  hence  its  effects  depend  on  its 
situation  and  size.  Even  a  large  innocent  tumour  in  the  sub- 
cutaneous tissue  will  produce  no  ill  effects  when  not  so  situated  as 
to  cause  pressure  on  important  organs  {e.g.  the  trachea),  whereas 
quite  a  small  one  implicating  the  central  nervous  system  or  other  part 
of  vital  importance  is  of  serious  moment,  not  as  being  a  tumour  but 
mechanically,  for  a  foreign  body  would  be  equally  harmful.  The 
more  rapidly  a  tumour  grows  the  more  will  its  mechanical  effects  be 
evident,  since  the  surrounding  structures  have  not  time  to  adapt 
themselves  to  the  presence  of  the  mass. 

Innocent  tumours  never  cause  death  unless  they  mechanically 
interfere  with  parts  of  vital  importance. 

The  malignant  growths  similarly  induce  mechanical  effects,  but 
quite  apart  from  these  they  inevitably  kill.  The  causes  of  death  in 
such  cases  may  be  quite  evident,  or  very  obscure  (see  p.  229). 

The  clinical  characters  of  tumours. — Clinically  a  tumour 
is  innocent  or  malignant — a  point  of  primary  importance  to  deter- 
mine in  diagnosis. 

Innocent  tumours  are  usually  strictly  circumscribed  and  are 
enclosed  in  a  more  or  less  dense  capsule  of  areolar  or  fibrous  tissue. 
They  do  not  infiltrate  the  tissues  among  which  they  lie,  but  if  sub- 
cutaneous, may  lead  to  sloughing  of  the  integuments  through 
pressure.       They    grow    slowly    and    may   degenerate,    but    such 


XI  TUMOURS 


229 


degeneration  is  rarely  extensive  or  rapid.  After  attaining  a  certain 
size  they  may  remain  stationary  indefinitely.  Innocent  tumours  are 
usually  freely  movable,  do  not  recur  after  complete  removal,  and 
never  give  rise  to  secondary  deposits.  Their  density  varies  with 
their  structure.  All  tumours  except  the  sarcomata  and  cancers  are 
innocent. 

Malig^nant  tumours  comprise  sarcomata  and  cancers,  but  the 
malignancy  is  not  equal  in  all,  nor  is  it  shown  in  the  same  way. 

A  tumour  may  be  malignant  locally,  generally,  or  both.  By 
local  maligfiancy  we  mean  that  the  growth  infiltrates  and  destroys 
the  tissues  by  continuity ;  all  forms  are  locally  malignant,  and  some, 
e.g.  rodent  cancer,  are  only  so.  Jjeneral  malig?iancy  is  characterised 
by  the  formation  of  secondary  deposits  in  the  glands,  internal 
organs  or  distant  parts  through  the  dissemination  of  the  cells  of  the 
primary  growth.  This  tendency  to  dissemination  varies  very  much 
in  the  different  forms  of  growth,  thus  myeloid  sarcoma  rarely,  and 
melanotic  sarcoma  invariably,  leads  to  secondary  deposits,  which 
may  be  very  numerous ;  again,  epithelioma  always  affects  the 
neighbouring  lymphatic  glands,  but  deposits  in  the  viscera  are  of 
great  rarity,  whereas  the  glandular  carcinomata  almost  always  lead 
to  numerous  visceral  deposits.  Sarcomata  spread  by  the  blood- 
stream, carcinomata  by  the  lymphatics.  In  what  this  malignancy 
consists  we  cannot  at  present  say;  Cohnheim  has  suggested  that 
the  invasion  of  the  tissues  might  be  dependent,  in  the  case  of 
cancer,  upon  the  diminished  resistance  offered  by  them  in 
consequence  of  the  degeneration  and  loss  of  compactness  occurring 
with  advancing  years ;  but  such  an  explanation  is  far  from 
convincing,  especially  when  we  reflect  that  cancer  occurring  at 
early  periods  of  life  is  remarkably  malignant. 

If  we  are  prepared  to  admit  the  parasitic  origin  of  malignant 
tumours,  the  parasites  being  capable  of  indefinite  growth  in  the 
body  and  possessing  varying  degrees  of  virulence,  we  have  a  rational 
explanation  of  malignancy.  It  is  quite  evident  that  there  is  some 
inherent  vice  in  the  cells  of  a  malignant  tumour,  and  that  the  pres- 
ence of  the  growth  induces  some  profound  alteration  in  general 
nutrition.  In  many  cases  it  is  quite  impossible  to  say  why  a  malig- 
nant tumour  kills.  It  is  true  that,  as  in  the  innocent  growths,  death 
may  result  from  implication  of  some  part,  the  integrity  of  which  is 
of  vital  importance,  or  may  result  from  exhaustion  consequent  on 
sloughing  or  repeated  and  profuse  hsemorrhage ;  but  in  many  cases 
no  such  causes  are  present,  and  post-mortem  examination  reveals 
no  lesions  of  a  lethal  nature.     Take,  for  example,  a  case  of  epi- 


2  30  MANUAL   OF  SURGERY  chap. 

thelioma  of  the  hand  with  involvement  of  the  lymphatic  glands ; 
the  patient  will  inevitably  succumb.  In  such  a  case  there  is  cer- 
tainly no  interference  with  any  essential  structure,  nor  is  there  any 
sufficient  drain  on  the  system  to  cause  the  cachexia,  emaciation,  and 
death,  and  epithelial  cells  themselves  have  certainly  no  poisonous 
properties.  If  we  accept  the  parasitic  origin  of  malignant  growths 
we  may  provisionally  assume  that,  as  in  the  case  of  the  infective 
diseases,  some  poisonous  materials,  formed  as  the  result  of  the 
activity  of  the  parasites,  are  poured  into  the  blood  and  produce 
toxic  effects. 

General  signs  of  ?nallgnancy. — At  first  the  tumour  is  quite  local- 
ised, and  some  of  the  sarcomata  may  be  encapsuled.  As  growth 
rapidly  proceeds,  the  circumscription  of  the  tumour  becomes  less 
evident  as  it  invades  and  infiltrates  the  surrounding  structures ; 
gradual  invasion  and  replacement  of  the  tissues  by  the  growth  may 
lead  to  perforation  of  the  skin,  mucous  membrane,  or  hollow  viscera, 
and  the  tumour,  freed  of  all  restraint,  fungates  and  increases  still 
more  rapidly.  The  size,  vascularity,  and  softness  of  a  malignant 
tumour  vary  with  its  precise  nature,  and,  to  a  less  extent,  with 
its  situation.  Malignant  tumours  undergo  rapid  and  extensive 
degeneration ;  they  tend  to  progressively  increase  in  size  and  repro- 
duce themselves  in  distant  parts,  to  recur  after  removal,  to  under- 
mine the  general  health  and  cause  death  ;  and  they  never  terminate 
in  spontaneous  cure. 

The  production  of  secondary  deposits. — Secondary  deposits  always 
faithfully  mimic  in  structure  and  behaviour  the  parent  growth,  but 
they  are  often  softer  and  grow  more  rapidly.  They  are  due  to  the 
transplantation  of  cells  of  the  primary  growth,  which  are  carried  to 
the  various  parts  of  the  body  by  the  blood-stream  (Fig.  6i,  p.  251) 
or  by  the  lymph.  Cancer  cells  invade  the  lymphatic  structures, 
whence  the  almost  constant  involvement  of  the  glands ;  they  also 
enter  the  blood- stream  by  the  lymphatic  ducts.  Sarcomata  are 
destitute  of  lymphatics,  and  hence  dissemination  occurs  by  the 
blood-stream  alone,  and  is  favoured  by  the  anatomical  characters  of 
the  vessels  of  these  tumours  (see  p.  232). 

Embolic  transplantation  explains  why  the  secondary  growths  are 
like  the  primary  in  structure,  and  the  frequency  with  which  they 
occur  in  the  lungs  and  liver. 

Secondary  growths  may  be  very  numerous  and  are  often  large, 
and  each  may  serve  as  a  centre  for  the  diffusion  of  fresh  emboli. 

Classification  of  tumours.  —  In  the  present  state  of  our 
knowledge  as  regards  etiology,  a  thoroughly  satisfactory  classifica- 


XI  TUMOURS  231 

lion  of  tumours  is  impossible,  but  they  may,  for  all  practical  pur- 
poses, be  convenicnily  separated  into  .groups  according  to  their 
anatomical  structure.  It  must  be  remembered,  however,  that  all 
tumours  are  composed  of  more  than  one  type  of  tissue — for  in- 
stance, all  have  blood-vessels  and  connective  tissue  elements,  and 
many  of  them  are  "mixed,"  that  is,  are  made  up  of  various  tissues, 
no  one  of  which  specially  predominates. 

Class  i.— Tumours  of  the  Type  of  Embryonic  Connective 

Tissue 

Sarcomata.  (Malignant.) 

Class  2.— Tumours  of  the  Type  of  fully-developed 
Connective  Tissue 

Lipomata. 

Fibromata. 

]\Iyxomata. 

Chondromata. 

Osteomata, 

Odontomata. 


(Innocent.) 


Class  3.— Tumours  of  the  Type  of  the  Higher  Tissues 

Myomata.  ^ 

Neuromata.  '.(Innocent.) 

Angiomata.  I 

Lymphangiomata.  J 

Class  4.— Tumours  of  the  Epithelial  Type 

Psammomata.  1 

Papillomata.  -(Innocent.) 

Adenomata,  j 
Carcinomata.  (Malignant.) 

Class  5. — Congenital  Tumours 

Teratomata.  \(innocentO 

Dermoids.  J 

Cysts   will  be  considered  at  the   end  of  this  chapter,  many  of 
them  not   being  tumours    according  to   the    definition   given    (see 

p.     2  2  2\ 


232  MANUAL  OF   SURGERY  chap 

Class  i. — Tumours  of  the  Type  of  Embryonic 
Connective  Tissue 

sarcomata 

Distribution. — Sarcomata  occur  more  frequently  before  than 
after  thirty  years  of  age,  but  no  period  of  life  is  exempt.  They 
may  grow  in  any  part  of  the  body,  but  most  frequently  affect  the 
skin  and  subcutaneous  tissue,  the  periosteum,  bones,  secreting 
glands,  and  the  supporting  connective  tissue  framework  of  the 
viscera. 

Morbid  anatomy. — These  tumours  are  composed  of  densely 
packed  masses  of  nucleated  cells,  which  vary  in  shape  and  size  in 
the  different  forms  to  be  presently  mentioned,  with  a  very  delicate 
connective  tissue  stroma  penetrating  between  the  individual  cells. 
This  stroma,  except  in  alveolar  sarcoma,  is  always  difficult  of  recog- 
nition and  may  be  quite  absent,  in  which  case  the  cells  are  held 
together  by  a  homogeneous  intercellular  substance.  The  softer  and 
more  rapidly-growing  sarcomata  are  the  most  likely  to  be  devoid  of 
a  stroma.  As  a  rule  sarcomata  are  very  vascular,  but  there  is  much 
variation  in  this  respect ;  sometimes  the  vessels  are  so  large  and 
numerous  that  the  tumour  pulsates  and  a  bruit  may  be  heard. 
Capillary  vessels  predominate,  but  numerous  venous  trunks — often 
of  large  size — may  be  present,  especially  in  the  softer  growths. 
The  vessel  walls  are  so  thin  that  the  blood  was  at  one  time  supposed 
merely  to  flow  in  channels  between  the  cells  without  any  limiting 
wall  This  fact  explains  the  frequency  with  which  sarcomata  grow 
into  large  veins,  the  occurrence  of  extensive  haemorrhage  with  the 
formation  of  blood  cysts  in  their  substance,  and  the  production  of 
secondary  growths  by  embolic  transplantation. 

Lymphatics  have  never  been  demonstrated,  and  hence  involve- 
ment of  the  lymphatic  glands  is  by  no  means  so  constant  and 
characteristic  as  in  cancer ;  but  in  sarcoma  of  the  tonsil  or  testis 
the  glands  are  invariably  involved.  Sarcomata  may  possess,  but 
are  usually  destitute  of,  a  capsule.  They  tend  to  infiltrate  the  sur- 
rounding structures,  growing  in  the  direction  of  least  resistance, 
and  may  invade  and  destroy  the  skin  and  fungate  on  the  surface, 
forming  a  large,  sloughy  mass  which  may  bleed  profusely. 

Sarcomata  are  specially  prone  to  early  and  extensive  degenera- 
tion. Fatty  and  myxomatous  changes  leading  to  softening  and  the 
formation  of  cysts  are  common  ;  ossific  changes  are  prone  to  occur, 
and  are  sometimes  very  extensive  in  sarcomata  of  bone  and  peri- 


XI  SARCOMATA  233 

osteum  (Fig.  47,  p.  227).  Cysts  may  also  arise  from  haemorrhage 
and  degeneration  with  softening. 

Clinical  characters. — In  most  cases  sarcomata  grow  rapidly, 
induce  constitutional  symptoms  common  to  all  malignant  disease, 
become  disseminated  in  the  lungs,  liver,  and  other  parts  of  the 
body,  and  eventually  cause  death.  The  softness  varies  in  the 
different  forms ;  sometimes  it  is  so  marked  that  palpation  conveys 
to  the  hand  a  sense  of  fluctuation  ;  in  other  cases  the  density 
is  as  great  as  that  of  a  fibroid  tumour.  The  vascularity  similarly 
differs.  A  sarcoma  is  more  or  less  circumscribed,  but  may  have 
bosses  and  processes  extending  in  directions  offering  but  little 
mechanical  resistance  to  invasion.  The  mobility,  pain,  and  general 
symptoms  induced  vary  with  the  seat  of  the  tumour.  The. skin 
over  a  sarcoma  is  often  marbled  by  congested  and  dilated  veins, 
and,  as  it  becomes  invaded  by  the  growth,  is  thinned,  stretched, 
and  of  a  livid  colour.  1 

As  the  tumour  grows  the  general  health  suffers,  and  the  patient 
emaciates,  the  cachectic  condition  increasing  as  secondary  growths 
appear. 

The  local  and  general  malignancy  of  the  sarcomata  vary  within 
wide  limits.  Myeloid  and  some  forms  of  spindle-celled  sarcoma 
show  very  little  tendency  to  become  generalised,  and  their  local 
malignancy  is  so  slight  that  early  and  free  removal  may  be  followed 
by  permanent  cure ;  on  the  other  hand,  while  the  local  malignancy 
of  melanotic  sarcoma  is  slight,  it  has  a  greater  general  malignancy 
than  has  any  other  known  tumour. 

Varieties  of  sarcomata. — Round-celled  sarcomata  are  very 
common  and  may  occur  at  any  age.  The  cells,  which  may  be 
large  or  small,  contain  a  relatively  large  nucleus,  and  are  sur- 
rounded by  a  small  quantity  of  homogeneous  intercellular  substance. 
In  some  cases  there  is  a  distinct  connective-tissue  stroma  like  that 
of  a  lymphatic  gland  (lympho-sarcoma  or  lymphoma).  Round-celled 
sarcomata  are  soft  and  highly  vascular,  grow  rapidly,  and  exhibit 
marked  malignant  properties  by  infiltrating  the  tissues  and  giving 
rise  to  secondary  deposits.  They  are  of  a  grayish  colour  on  section 
and  show  areas  of  fatty  degeneration,  softening,  and  hcxmorrhage. 
These  tumours,  when  fresh,  do  not  yield  a  milky  juice  on  scrap- 
ing. 

Lympho-sarcomata  are  especially  met  with  in  the  lymphatic  glands, 
toitfeil,  testis,  and  retro-peritoneal  tissue. 

A  glioma  is  a  round-celled  sarcoma  with  a  delicate  stroma  Lke 
neuroglia ;  it  chiefly  affects  the  eye  and  central  nervous  system.     A 


^34 


MANUAL  OF  SURGERY 


CHAP. 


glioma  is  usually  soft  but  may  be  firm.  It  infiltrates  the  brain 
substance  which  appears  hypertrophied,  the  tumour  having  no 
definite  limitation.      Secondary  deposits  are  rare. 

A  cylindroma  or  pkxiform  sarco?)ia  appears  to  be  due  to  a  de- 
generation of  the  round-celled  form.  The  cells  are  arranged  in 
columns  enclosing  vessels  surrounded  by  a  hyaline  myxomatous 
tissue  due  to  degeneration  of  the  vessel  walls  and  adjacent  cells. 
This  tumour  is  very  rare  and  chiefly  affects  the  brain. 

Alveolar  sarcoma  (Fig.  48)  consists  of  large  round  cells  con- 
tained in  the  meshes  of  a  definite  fibrous  stroma  similar  to  that 


Fig.  48. — Alveolar  sarcoma  of  a  lymphatic  gland  (Ziegler).     a,  stroma ;  b,  cell  nests  ; 
c,  alveoli  with  scattered  cells. 

seen  in  cancers,  but  differing  from  it  in  the  fact  that  finer  ramifica- 
tions penetrate  between  the  individual  cells.  Alveolar  sarcoma  is 
rare,  and  occurs  in  the  skin,  often  in  connection  with  moles.  The 
nodules,  which  are  rounded  and  hard,  but  do  not  attain  a  large 
size,  are  often  numerous,  and  after  a  time  break  down,  giving  rise 
to  persistent  sloughy  sores.  Occasionally  alveolar  sarcoma  occurs 
in  the  bones  or  muscles. 

Spindle-celled  sarcomata. — The  cells,  which  may  be  small  or 
large  (Fig.  49),  are  oat-shaped  or  fusiform,  with  a  homogeneous 
intercellular  substance.  They  are  arranged  in  more  or  less  dts- 
tinct  bundles  which  run  in  all  directions.  Each  cell  has  a  very 
large   nucleus,   and  the  protoplasm   is   often  very  scanty.      Rarely 


XI 


SARCOMATA 


235 


the  cells  present  cross-striations  resembling  voluntary  muscle  cells 
{myosarcoma  or  rhabdomyoma). 

The  stroma  may  be  abundant  and  of  a  fibrous  nature  {fibro- 
sarcoma) ;  islands  of  cartilage  {chondro- 
sarcoma) or  ossific  matter  {osteo-sar- 
cama)  are  not  uncommon.  Spindle- 
celled  sarcomata  are  often  encap- 
suled. 

To  the  naked  eye  a  spindle-celled 
sarcoma  resembles  the  round-celled, 
but  is  more  dense.  Clinically  these 
tumours  vary  in  the  rapidity  of  their 
growth  and  malignancy.  The  small- 
celled  variety  usually  grows  slowly 
and  closely  resembles,  both  in 
naked-eye  appearance  and  micro- 
scopically, a  fibroid  tumour  {recurrent 
fibroid). 

The  softer  the  growth,  and  the 
more  closely  the  cells  approximate 
to  the  embryonic  type,  the  greater 
the  malignancy.  If  recurrence  takes 
place  the  secondary  growths  progress 
more  rapidly,  show  greater  malignancy, 
and  possess  a  lower  type  of  cells  than 
did  the  primary  one.  The  small 
spindle-celled  sarcoma  is  much  less  m.alignant  than  is  the  large- 
celled  variety. 

Melanotic  sarcomata  are  composed  chiefly  of  spindle  cells  with 
round  cells  interspersed.  Dark  pigment  is  present  in  and  between 
the  cells ;  its  amount  varies  so  that  the  colour  of  the  tumour  may 
be  anything  from  gray  to  sooty-black.  The  surface  of  section  may 
have  a  marbled  or  granite -like  appearance  from  unequal  distri- 
bution of  the  pigment.  The  tumours  are  often  encapsuled,  quite 
localised,  and  do  not  attain  a  large  size ;  but  secondary  deposits 
may  be  almost  universal  and  very  numerous,  especially  in  the  liver. 
Melanotic  sarcomata  grow  primarily  in  pigmented  structures  such  as 
the  choroid ;  they  also  com.monly  occur  in  abnormally  pigmented 
spots,  e.g.  warts  and  moles.      They  are  highly  malignant. 

Myeloid  sarcoma  (Fig.  50,  p.  236)  grows  almost  exclusively  in 
the  cancellous  tissue  of  the  heads  of  long  bones,  and  from  the 
alveolar  borders  of  the  jaws  as  one  form  of  epulis. 


Fig.  49-  —  Spindle  cells  from  a  large 
spindle-celled  sarcoma  of  the  cheek 
(Ziegler). 


2T,6 


MANUAL   OF  SURGERY 


CHAP. 


The  tumour  is  composed  of  round  and  spindle-shaped  cells,  with 
a  number  of  multi-nucleated  giant  cells,  which  are  usually  branched 

and    resemble    those  normally 
met   with    in    the    medulla    of 
bones.      The  blood-vessels  are 
®=  "^  >^==P^^^^;^tA  >-,,irr,oT-rMic    and  in  some  cases 


-=>^ 


^  I 


^ 


Fig.  50. — Cells  from  a  mj-eloid  sarcoma  of 
the  tibia  (Zeigler). 


numerous, 

the  tumour  may  pulsate  when 
it  has  perforated  the  bone  and 
infiltrated  the  soft  structures. 
Cysts  are  not  uncommon. 

On  section,  a  myeloid  sar- 
coma is  of  a  pinkish  hue,  with 
maroon-coloured  areas  due  to 
extravasation.  Myeloid  sarco- 
mata are  not  very  malignant 
locally,  and  secondary  deposits 
are  of  great  rarity. 

Mixed  sarcomata  are  very 

common.      Gland  tissue,  bone, 

cartilage,   fibrous   and   mucous 

tissue    are   frequently  present, 

and  sometimes,  e.g.  in  the  parotid  and  testis,  give  rise  to  the  most 

complex  growths. 

Cysts  of  new  formation  or  due  to  degeneration  or  haemorrhage 
are  frequently  present. 

Treatment  of  sarcomata. — Early  and  wide  removal  is  called 
for  in  all  cases  where  the  situation  or  extent  of  the  tumour  holds  out 
a  chance  of  success.  The  means  of  removal  varies  with  the  situation 
Sarcomata  should  never  be  squeezed  or  roughly  handled  during  an 
operation,  for  fear  of  detaching  cells  growing  into  the  vessels,  and 
hence  inducing  secondary  growths  by  embolism. 

The  success  of  the  operation  depends  in  great  measure  on  the 
variety  of  the  sarcoma ;  partly  also  on  its  seat.  Sarcomata  of  the 
jaw,  femur,  and  kidney  are  very  likely  to  be  followed  by  rapid 
recurrence ;  so  marked  is  this  liability  in  sarcoma  of  the  kidney 
in  children  that  operative  treatment  appears  to  be  useless. 
Ghomata  of  the  eye  are  treated  by  enucleation  of  the  globe ;  those 
of  the  brain  and  cord  are,  owing  to  their  diffusion,  not  amenable 
to  operative  treatment.  The  treatment  of  carcinomata  and  sarco- 
mata by  Coley's  fluid  is  referred  to  at  p.  253. 


XI  LIPOMATA  237 

Class  2. — Tumours  of  the  Type  of  fully-developed 
Connective  Tissue 

lipomata 

Causes. — Fatty  tumours  are  sometimes  traceable  to  irritation, 
but  in  the  majority  of  cases  no  cause  is  assignable.  The  tendency 
to  their  formation  is  sometimes  hereditary,  and  in  such  cases  they 
are  often  very  numerous  and  small. 

Distribution. — Commonly  met  with  in  the  subcutaneous  tissue 
about  the  shoulders  and  back,  lipomata  may  occur  in  any  part 
normally  containing  fat,  A  diffuse  form,  highly  vascular  and  not 
encapsuled,  is  sometimes  met  with  about  the  neck  in  middle-aged 
men,  especially  beer-drinkers ;  it  may  attain  enormous  proportions 
and  form  a  complete  collar.  Lipomata  may  grow  beneath  mucous 
or  serous  membranes,  among  muscles,  and  in  connection  with  the 
periosteum.  They  are  not  uncommon  above  the  clavicle.  A 
specimen  in  the  Westminster  Hospital  Museum  shows  a  large  fatty 
tumour  growing  beneath  the  mucous  membrane  of  the  pharynx, 
which  caused  death  from  suffocation. 

Subperitoneal  lipomata  may  attain  a  very  large  size  in  the 
abdomen  and  may  simulate  sarcom^ata  or  ovarian  cystic  disease. 
Not  infrequently  small  fatty  tumours,  originating  in  the  subperi- 
toneal fat,  descend  along  the  spermatic  cord  or  into  the  crural 
canal,  and  simulate  or  conceal  a  hernia.  In  other  cases  fatty 
tumours  arise  in  the  small  masses  of  fat  which  are  present  at  the 
apertures  of  exit  of  the  small  blood-vessels  in  the  abdomen  and 
chest. 

Parosteal  lipomata  are  rare,  and  are  usually,  if  not  always,  con- 
genital ;  they  chiefly  affect  the  long  bones  and  are  likely  to  be 
confounded  with  sarcomata. 

Morbid  anatomy. — A  fatty  tumour  is  a  lobulated  mass  of 
fat,  quite  smooth  on  the  surface  and  contained  in  a  delicate  con- 
nective-tissue capsule,  which  is  but  slightly  adherent  to  the  tumour, 
though  more  intimately  so  to  the  overlying  skin,  causing  it  to  pucker 
when  pinched  up  between  the  finger  and  thumb.  Fatty  tumours 
niay — apparently  as  the  result  of  gravity — shift  their  position,  or 
become  more  or  less  pedunculated,  in  which  case  further  growth 
may  be  impeded  or  arrested  through  interference  with  the  circula- 
tion due  to  torsion. 

The  vessels  are  usually  small  and  unimportant,  but  may  form  a 
prominent  feature  of  the  growth  (naivo-lipoma) ;  such  cases  are  often 


238 


MANUAL  OF  SURGERY 


CHAP. 


congenital    and  widespread.      Fibro-lipoma   and    myxo-lipoma  are 

varieties  the  structure  of  which  is  indicated  by  their  names. 

Large  fatty  tumours  may  lead  to  ulceration  of  the  skin  through 

pressure.     Occasionally  an    abscess  forms    in   the    middle    of   the 

growth. 

Calcification  sometimes  occurs  round  the  more  central  part  of 

old  lipomata,  the  included  portion  having  a  soapy,  adipocere-like 

appearance. 

Lipomata    may  attain  enormous    dimensions  and  weigh  many 

pounds. 

Clinical   characters. — Fatty  tumours   form   slowly,   and  are 

perfectly   innocent ;  but   if  a   small  portion   has   been  left   during 

removal  it  will  continue 
to  grow.  The  effects 
produced  are  purely 
mechanical. 

A  subcutaneous 
lipoma  forms  a  freely 
movable,  painless,  soft, 
lobulated  tumour,  the 
edge  of  which  slips 
away  from  under  the 
finger.  It  is  slightly 
adherent  to  the  skin. 

Deeply-seated  lipo- 
mata cause  more  or  less 
difficulty  in  diagnosis, 
which  may  be  impos- 
sible. Fatty  tumour  in 
the  palm  of  the  hand 
is  not  uncommon,  and 
is  often  congenital ;  it 
must  not  be  mistaken 
for  ganglion. 

In  the  lumbo-sacral 
region,  fatty  growths 
sometimes  conceal  the 
sac    of  a   spina  bifida, 

Fig.  51.— Lipoma  in  the  palm  of  the  hand  (Bland  Sutton).        and  any        Operation 

must,   in    view   of  this 
contingency,  be  conducted  with  the  greatest  caution. 

Treatment. — Diffuse  lipoma  and  large  diffuse  nsevo-lipomata 


XI  .  FIBROMATA  239 

should  not  be  interfered  with,  no  treatment  having  hitherto  proved 
of  any  avail,  although  liquor  potass^e  in  the  former  and  compression 
of  the  main  vessel  in  the  latter  form  have  been  advocated  and  tried. 
If  lipomata  are  numerous  they  are  usually  small,  remain  stationary 
after  a  time,  and,  as  a  rule,  need  not  be  removed.  The  question  of 
operation  in  the  case  of  fatty  tumours  in  special  regions  must  be 
decided  according  to  the  circumstances  of  each  case. 

Subcutaneous  lipomata  are  very  readily  and  safely  removed. 
The  incision  should  be  long  enough  to  enable  all  lobules  to  be 
removed,  and  should  open  the  capsule  freely,  when  the  tumour  can 
readily  be  enucleated  with  a  few  touches  of  the  knife. 


FIBROMATA 

Distribution. — Pure  fibromata  are  rare  tumours,  but  fibrous 
tissue  enters  more  or  less  prominently  into  the  formation  of  m.ost 
new  growths.  Fibrous  tumours  occur  in  and  beneath  the  skin  as 
molluscum  fibrosum,  keloid,  and  painful  tubercle.  They  may  also 
be  met  with  in  connection  with  the  periosteum,  especially  as  simple 
epulis  and  naso-pharyngeal  polypus,  and  occasionally  grow  in  the 
interior  of  long  bones.  In  connection  with  nerve-sheaths  they  form 
one  variety  of  false  neuromata.  Fibroid  tumours  of  the  ovary  are 
sometimes  met  with,  and  the  common  tumours  of  the  uterus  and 
prostate  consist  largely  of  fibrous  tissue. 

Morbid  anatomy. — Normal  fibrous  tissue  varies  in  its  softness 
and  density,  and  similarly  fibromata  are  soft  or  hard,  but  they  both 
consist  of  fusiform  cells  with  large  nuclei.  The  fibres  are  collected 
into  wavy  bundles,  and  scattered  among  them  are  numerous  small 
round  cells.  These  bundles  of  fibres  are  often  arranged  more  or 
less  concentrically.  Vessels  are  usually  small  and  few,  but  they  may 
be  very  large  and  numerous. 

Fibromata  are  usually  encapsuled  and  grow  slowly.  They  are 
not  very  prone  to  degenerate,  but  may  become  fatty  or  calcareous, 
and  sometimes  cystic  from  softening.  They  are  perfectly  innocent. 
The  so-called  recurrent  fibroid  is  a  spindle-celled  sarcoma,  and  it 
may  be  extremely  difficult — sometimes  impossible — to  say  definitely 
from  the  general  characters  and  microscopic  appearance  of  a  tumour 
whether  it  is  a  fibroma  or  a  spindle-celled  sarcoma. 

Clinical  characters. — The  clinical  features  of  fibromata  de- 
pend upon  their  situation,  and  the  special  form  of  the  growth. 

Fibromata  of  bene  are  of  the  hard  variety,  and  are  clinically 
indistinguishable  from  sarcomata. 


240  MANUAL   OF  SURGERY  chap. 

Keloid  is  described  in  chap,  ii.  vol.  ii. 

Painful  subcutaneous  tubercle  is  a  small  firm  fibroma  growing 
in  the  subcutaneous  tissue,  especially  that  of  the  extremities.  Women 
are  much  more  frequently  affected  than  men.  These  tumours  are 
usually  multiple,  and  may  be  very  numerous  ;  they  grow  slowly,  never 
attain  a  size  much  larger  than  that  of  a  pea,  and  may  remain  sta- 
tionary for  many  years.  Very  often  the  tubercles  are  so  small  that 
they  do  not  cause  any  visible  signs,  and  are  only  recognisable  by 
feeling,  attention  being  drawn  to  them  by  the  pain,  which  is  their 
chief  characteristic.  Such  pain  is  usually  paroxysmal  and  radiating, 
and  may  be  extremely  severe,  suggesting  the  association  of  the 
growth  with  nervous  filaments,  but  none  such  have  ever  been 
found. 

Molluseum  fibrosum  is  a  soft  fibroma  or  fibro-cellular  tumour 
springing  from  the  skin  and  subcutaneous  tissue.  Numerous  nodules 
or  tumours  of  varying  size,  sometimes  enormous,  are  .present  in 
different  parts  of  the  body,  and,  owing  to  their  weight,  may  form 
large  pendulous  masses  or  pedunculated  growths,  which  are  often 
extremely  vascular.  Ulceration  may  occur  from  irritation  or  pres- 
sure, and  necessitate  removal  of  the  growth.  Solitary  growths  of 
similar  nature  (fibro-cellular  tumours)  are  sometimes  met  with,  especi- 
ally on  the  buttocks,  scrotum,  labia,  and  scalp.  They  are  usually 
pedunculated,  and  may  attain  a  very  large  size ;  they  are  very  soft, 
and  sometimes  cystic.  Fat  often  forms  a  prominent  feature  of  these 
growths.     They  may  be  readily,  and  as  a  rule  safely,  removed. 

Treatment. — Fibromata  of  bone,  fibro-cellular  tumours,  and 
painful  tubercles  should,  under  ordinary  circumstances,  be  removed. 

Keloid  should  not  be  touched,  as  it  will,  although  innocent, 
recur  in  the  cicatrix.  The  tumours  of  molluseum  fibrosum  should 
be  left  alone,  unless  ulceration  or  other  cause  demands  interference. 
The  treatment  of  fibromata  in  other  parts  of  the  body  will  be  dis- 
cussed in  the  proper  chapters. 

MYXOMATA 

Distribution.  —  Myxomata  usually  occur  as  pedunculated 
tumours — so-called  polypi — in  the  nose,  antrum,  frontal  sinuses, 
cervix  uteri,  and  sometimes  in  the  ear  and  alimentary  canal. 
Pedunculated  myxomata  often  grow  from  the  labia,  especially  in 
young  women. 

Morbid  anatomy. — ]\Iucous  tumours  are  composed  of  soft 
tissue  made  up  of  dehcate,  stellate,  and  branching  cells,  which,  by 


XI 


CHOXDROMATA 


241 


union  of  their  processes,  frequently  form  a  beautiful  network.     The 
main  bulk  of  the  growth  consists  of  a  characteristic,  glairy,  mucoid 
material.     The  mucous 
membrane  lining  the  cavity 
in  which  the  polypus  grows 
is  reflected  over  its  surface. 

Mucous  tissue  often 
forms  a  prominent  feature 
of  sarcomatous  growths 
(myxo-sarcoma),andmaybe 
met  with  in  other  tumours. 

Clinical  characters. 
— Myxomata  are  pinkish, 
soft,  gelatinous,  and  often 
lobulated  tumours,  attached 
by  a  pedicle.  They  are 
often  numerous.  The 
symptoms  they  cause  de- 
pend upon  the  situation  in 
which  they  grow. 

Treatment.  —  These 
tumours  are  easily  re- 
moved by  avulsion,  or  by     ^  ^  „  , 

•'  ^        Fig.  32. — Cells  from  a  m^'xoma  of  the  turbinate  bones 

the  galvanO-CaUtery  loop.  (mucous  polypus  of  the  nose),  (Ziegler). 


CHOXDROMATA 


Distribution. — Pure  chondromata  grow  in  connection  with 
bones.  The  mixed  sarcomatous  tumours  of  the  parotid  and  testis,  and 
occasionally  of  other  parts,  frequently  contain  a  considerable  amount 
of  embryonic  cartilage.  Chondromata  of  bone  may  grow  in  relation 
with  the  epiphyseal  cartilages,  in  the  interior  of  the  bone,  or  from 
the  perichondrium.  In  the  large,  long  bones  the  tumour  is  usually 
situated  at  the  end  of  the  diaphysis.  In  the  fingers,  the  centre  of 
the  shaft  is  more  commonly  affected,  because  in  these  bones  cartilage 
islands  are  frequently  found  (Fig.  46,  p.  223).  The  bones  chiefly 
affected  are  those  of  the  fingers,  ribs,  pelvis,  and  the  lower  end  of 
the  femur  and  upper  end  of  the  tibia.  Sometimes  chondromata 
grow  in  connection  with  the  lar)-ngeal  cartilages.  Chondromata, 
especially  of  the  fingers,  are  frequently  multiple  (Fig.  53,  p.  242^, 

VOL.  I  R 


242 


MANUAL  OF  SURGERY 


CHAP. 


and  may  attain   a   considerable  size.      They  are  met  with  in  early 

life. 

Morbid  anatomy. — The  tumour  is  encapsuled,  and  consists  of 

pure  hyaline  cartilage,  sometimes  with 
cells  of  the  embryonic  type.  It  has  been 
shown  that  in  some  cases,  especially  in 
rickety  subjects,  chondromata  originate 
from  included  cartilage  islands.  These 
growths,  sometimes  lobulated,  are  hard 
and  dense  in  structure,  develop  slowly, 
and  are  prone  to  ossification,  calcifica- 
tion, and  mucoid  softening.  Chon- 
dromata of  a  phalanx  grow  in  the 
interior  of  the  bone,  which  is  thinned 
and  expanded ;  but  as  the  tumours 
increase  in  size  the  investing  shell  of 
bone  may  be  perforated,  and  the  tum- 
our, no  longer  confined,  grows  more 
rapidly.        Pure    chondromata  are   inno- 

FiG.     53.  —  Chondromata    of    the    cent. 

second    metacarpal    bone    and  , .     .       ,       ,  , 

first  phalanx  of  the  index  finger,  Thc  clmical  ctiaracters  and  treatment 

which  necessitated  amputation    „    „    j    „„  :u^J   :^    ^U^^*-^-  ,,     .,^1     i'^\ 

(Fergusson).  ^^e  describeu  m  chapter  v.  vol.  ni. 


OSTEOMATA 

Varieties. — Pure   osteomata   may  be   formed   of  compact   or 
cancellous  tissue. 

Distribution. — The  compact  osteoma  grows  in  connection 
with  bones  primarily  developed  in  membrane, 
viz.  the  vertex  of  the  skull,  the  frontal  sinuses, 
clavicle,  and  lower  jaw,  being  most  common 
in  the  first  situation.  They  also  occur  in  the 
external  auditory  meatus.  The  cancellous 
osteoma  is  merely  an  ossified  chondroma,  and 
is  met  with  in  connection  with  the  epiphysary 
ends  of  the  diaphysis  of  long  bones.  A  can- 
cellous osteoma,  regarded  by  Sutton  as  of 
inflammatory  origin,  is  not  uncommon  on 
the  dorsal  aspect  of  the  terminal  phalanx  of 
the  great  toe  {subungual  exostosis). 

Morbid  anatomy. — The  compact  or  ivory  osteoma  (Fig.  55) 
is   extremely   dense   and   hard,    so   that   it  is  removed  with   great 


Fig.  54. — Subungual  exos- 
tosis on  the  great  toe 
(Bland  Sutton). 


XI 


OSTEOMATA 


243 


difficulty.      It  is  broadly  sessile,  and  often  resembles  a  limpet-shell 
in  shape.      On  section  the  surface  is  ivory-like. 

The  cancellous  op  spongy  osteoma  (Fig.  56)  is  an  advanced 
stage  of  growth  of  the  ossifying  chondroma. 
It  consists  of  cancellous  tissue  similar  to  and 
continuous  with  that  forming  the  interior  of 
the  bone  from  which  it  grows.  The  tumour, 
which  may  be  rounded  or  nodular,  is  capped 
with  cartilage  undergoing  ossification,  and  is 
frequently  covered  by  a  bursa.  Cancellous 
osteomata  are  sessile  or  pedunculated ;  in  the 


Fig.  55. — Ivory  osteoma  of 
the  frontal  bone  (West- 
minster Hospital  Mu- 
seum, No.  244.  Drawn 
by  C.  H.  Freeman). 

latter     case     the     growth 
has  increased  peripherally, 
while    the    base   has  ossi- 
fied     and       consequently 
ceased  to  enlarge.     In  some  cases  a  pedun- 
culated   growth    may   separate    by   a    process 
similar    to    that    by    which    deer    shed    their 
antlers.      A  cancellous  osteoma  usually  ceases 
to  grow  when  the  development  of  the  bone 
from  which  it  springs  is  completed. 

Clinical  characters.  —  Osteomata  may 
be  distinguished  by  their  density,  slow  growth, 
and  position.  They  are  painless  unless  causing 
pressure  on  a  ner\-e.  Special  symptoms  may 
be  induced  from  the  situation  of  the  growth ; 
thus  deafness  results  in  the  case  of  involve- 
ment of  the  auditory  meatus,  and  cerebral 
Fig.  56.--Cancellous  osteoma  qj-   ocular   symptoms  from  the  presence   of  a 

of  the  upper  end    of  the  ,.  i  •  r      u        r  i 

diaphysis   of  the    tibia  growth  from  the  mner  aspect  01   the   trontal 

{Zie2ler).  i 

^     °  bone. 


Treatment. - 
chap.  V.  vol.  iii.). 


-Removal   is    the   only   available   treatment  (see 


2  44  MANUAL   OF   SURGERY  chap 


ODONTOMATA 

Varieties. — "An  odontome  is  a  tumour  composed  of  dental 
tissues  in  varying  proportions  and  different  degrees  of  develop- 
ment, arising  from  tooth-germs,  or  teeth  still  in  the  process  of 
growth."  1 

Odontomata  are  divided  into  varieties  according  to  their  origin 
from  the  different  parts  of  the  developing  tooth.  The  epithehal 
odontome  or  enamel  organ  tumour,  and  the  follicular  odontome  or 
dentigerous  cyst  are  described  with  diseases  of  the  jaws  (chap.  xiv. 
vol.  iii.). 

The  fibrous  odontome  arises  from  thickening  and  overgrowth 
of  the  tooth-sac,  whereby  a  fibrous  tumour  is  formed,  which  often 
encloses  and  encapsules  the  developing  tooth.  A  similar  process, 
affecting  many  adjacent  tooth-sacs  and  accompanied  by  ossification 
of  the  fibrous  tissue  which  encloses  numerous  portions  of  un- 
developed teeth  or  fragments  of  cement,  gives  rise  to  the  com- 
pound follicular  odontome. 

Radicular  odontomes  consist  of  cement  and  dentine,  and  affect 
the  roots  of  teeth  after  the  crown  has  been  fully  developed ;  hence 
enamel  is  not  present  in  this  form  of  tumour. 

Composite  odontomes  are  composed  of  all  the  elements  present 
in  a  normal  tooth,  but  in  a  rudimentary  state  of  development.  They 
affect  more  than  one  tooth-germ  and  may  attain  a  large  size. 

Clinical  characters. — Odontomata  give  rise  to  swelling  and 
enlargement  of  the  jaw  and  all  the  signs  of  a  tumour.  As  growth 
proceeds  the  tumour  tends  to  come  through  the  gum  and  displace 
the  teeth  in  its  neighbourhood. 

Considerable  inflammation  and  suppuration  is  excited,  and 
hence  many  of  these  cases  have  been  unrecognised  and  treated  for 
necrosis  or  a  tumour  of  a  malignant  nature. 

Odontomes  are  met  with  in  early  life  after  the  second  dentition  ; 
they  grow  slowly,  and  are  at  first  painless,  but  as  inflammation  is 
excited  pain  may  be  very  severe.  In  all  cases  of  doubt  the  tumour 
should  be  carefully  examined  and  neighbouring  teeth  extracted 
before  removal  of  a  part  of  the  jaw  is  decided  upon. 

Treatment. — The  odontomes  above  described  may  usually  be 
readily  enucleated  by  the  gouge  and  elevator.  The  operation 
should  always  be  conducted  through  the  mouth  and  the  tumour  be 
fully  exposed  by  cutting  down  through  the  gum. 

^  Bland  Sutton,  Tumours,  Innocent  and  Malignant,  p.  31. 


XI  MYOMATA  245 

Class  3. — Tumours  of  the  Type  of  the  Higher  Tissues 

MYOMATA 

Varieties  and  distribution. — Striped  or  voluntary  muscle 
tissue  is  sometimes  met  with  in  sarcomatous  growths,  especially  in 
congenital  renal  tumour  (rhabdomyoma). 

Leiomyomata  or  tumours  of  unstriped  muscle  are  mixed  with 
fibroid  tissue  and  are  common  in  the  uterus.  They  are  also  met 
with  in  connection  with  the  ovary,  Fallopian  tubes,  broad  ligament, 
and  prostate ;  more  rarely  in  the  walls  of  the  bladder,  oesophagus, 
and  other  muscular  organs. 

Morbid  anatomy. — Fibro-myomata  are  encapsuled  tumours 
varying  in  density  and  rapidity  of  growth  according  to  the  amount 
of  fibrous  tissue  as  compared  with  the  muscular.  The  cells  are 
long  and  fusiform  with  elongated  nuclei,  and  are  arranged  con- 
centrically, so  that  the  surface  of  section  has  a  whorled  appearance. 
Their  vascularity  varies  within  the  widest  limits.  Fibro-myomata  of 
the  uterus  may  attain  an  enormous  size,  and  are  often  composed  of 
many  masses  bound  together  by  areolar  tissue ;  they  may  be 
situated  within  the  thickness  of  the  wall  (intramural)  or  project 
beneath  the  peritoneal  covering  (subperitoneal)  or  mucous  lining 
(submucous) ;  in  either  of  the  two  situations  they  may  become 
pedunculated,  and  either  cease  to  grow  through  interference  with 
the  blood-supply,  or  actually  slough  or  suppurate  if  the  latter  be 
acutely  or  gradually  obliterated  by  torsion  of  the  pedicle. 

Fibro-myomata  may  degenerate  or  soften,  and  may  become 
almost  completely  calcified.     Cysts  from  degeneration  are  common. 

Clinical  characters. — These  tumours  are  quite  innocent,  usually 
grow  slowly,  and  induce  symptoms  according  to  their  situation. 

Treatment. — Removal  when  practicable.  Uterine  fibro-myo- 
mata are  rarely  amenable  to  removal  (see  chap.  xxix.  vol.  iii.). 

neuromata 

A  true  neuroma  is  a  tumour  composed  of  nervous  elements ;  a 
growth  in  connection  with  a  nerve,  but  not  so  constructed,  is  a  false 
neuroma  (see  Diseases  of  Nerves,  chap.  viii.  vol.  iii.). 

ANGIOMATA 

Angiomata  are  tumours  composed  of  blood-vessels  with  a 
supporting  framework  of  connective  tissue.     The  vessels  normal  to 


246  MANUAL  OF  SURGERY  chap. 

the  part  are  dilated,  their  walls  thickened,  and  they  are  much 
increased  in  number.  Angiomata  are  almost  always  congenital,  but 
in  some  situations,  e.g.  the  liver,  they  are  said  to  occur  in  later  life. 
They  may  consist  chiefly  of  capillary  vessels  (capillary  nsevus), 
of  veins  (venous  or  cavernous  nsevus),  or  of  arteries  (cirsoid 
aneurism).  These  tumours  are  fully  described  under  Diseases  of 
Blood-vessels  (chap.  i.  vol.  iii.). 


LYMPH  A!;GI0MATA 

The  lymphatic  vessels  may  by  dilatation  and  enlargement  give 
rise  to  a  lymphatic  naevus.  Macrog'lossia  is  practically  a  lym- 
phatic naevus  of  the  tongue  (chap,  xvi.  vol.  iii.). 

Cystic  dilatation  of  the  lymph-spaces  occasions  a  multilocular 
cystic  tumour  known  as  cystic  hygroma,  or  may  form  a  simple  serous 
cyst. 

These  conditions  are  fully  described  under  Diseases  of  the 
Lymphatics  (chap.  iv.  vol.  iii.),  and  Cysts  (p.  260). 


Class  4. — Tumours  of  the  Epithella.l  Type 
psammomata 

Psammoma  is  a  rare  tumour  met  with  in  connection  with  the 
choroid  plexus,  pituitary  body,  or  cerebral  membranes.  It  consists 
of  a  basis  of  fibrous  or  myxomatous  tissue,  with  flattened  epithelium 
cells  arranged  in  globe-like  masses  and  infiltrated  with  brain  sand. 

These  tumours  are  usually  quite  small,  perfectly  innocent,  and 
as  they  do  not  cause  symptoms  are  only  discovered  post-mortem. 
Psammoma  is  classed  by  some  pathologists  either  with  the  fibro- 
mata or  sarcomata. 

PAPILLOMATA 

Papillomata  are  tumours  formed  on  the  plan  of  norm.al  papillae, 
and  usually  arise  in  connection  with  them, 'but  some  growths  {e.g. 
the  villous  tumour  of  the  bladder)  belonging  to  this  class  occur 
in  situations  devoid  of  such  structures. 

Distribution. — Papillomata  are  common  on  the  skin,  the 
mucous  surfaces  of  the  vulva  or  glans  penis,  and  about  the  anus, 
and  present  in  different  situations  the  characters  of  corns,  warts,  or 
condylomata.       They   are    frequently   traceable    to    dirt,    moisture, 


XI  PAPILLOMATA  247 

and  irritation.  Papillomatous  growths  are  also  met  with  in  the 
urethral  canal,  in  the  bladder,  in  mammary  and  other  cysts  (p. 
260),  and  in  the  rectum. 

Morbid  anatomy.  —  Wherever  papillomata  occur,  their 
fundamental  structure  is  the  same,  but  they  assume  very  different 
clinical  appearances  owing  to  modifications  of  growth  and  situa- 
tion. A  papilloma  consists  of  a  basis  of  connective  tissue  con- 
taining blood-vessels,  and  sometimes  a  lymphatic ;  where  papillae 
exist  this  fundamental  structure  is  due  to  their  enlargement,  but  in 
surfaces  destitute  of  papillae  the  connective  tissue  basis  is  an  out- 
growth of  that  normal  to  the  submucous  tissue  of  the  part.  The 
papillary  processes  are  covered  by  layers  of  thickened  epithelium 
cells  which  always  remain  limited  to  the  surface,  and  do  not 
penetrate  and  invade  the  deeper  structures  as  in  the  case  of  cancer. 
Papillomata  may,  however,  become  malignant  from  irritation,  etc., 
and  then  the  epithelial  invasion  is  present. 

Papillomata  of  the  skin  are  not  infrequently  pigmented,  and 
sarcomatous  changes  may  occur  in  them. 

The  epithelial  covering  may  be  very  dense  and  hard,  as  in  a 
corn,   and    in    some    cases    develops    into    a 
decided    horn    (Fig.     57).      Papillomata     of 
mucous  membranes  are  more  usually  covered 
with  a  delicate  layer  or  layers  of  cells. 

The  papillomatous  processes  may  be  a 
very  insignificant  part  of  the  tumour,  and 
only  recognisable  by  the  microscope.  Thus 
a  corn  is  a  papilloma  composed  almost 
entirely  of  very  dense  and  hard  epithelium  FiGTlT^'^^Cuta^ous  hom 
which  compresses  the  papillae.  from   the   back  of  the 

rj.,  ^     .„  u  u       *.  •         .uU  hand  (Ziegler). 

The    papillae    may    be    short,    as   m    the 
ordinary  papilloma  of  the  skin ;  or  the  processes  may  be  very  long, 
branched,  and  delicate,  as  in  villous  tumours  of  the  bladder  (Fig. 
58,  p.  248)  and  duct  papillomata. 

The  density  and  vascularity  of  papillomata  vary  within  wide 
limits,  as  is  seen  when  we  contrast  a  corn  with  a  soft  and  highly 
vascular  papilloma  of  the  bladder. 

Clinical  characters. — All  papillomata  are  innocent  tumours, 
but  under  certain  conditions  they  assume  malignant  characters  as 
already  stated.  The  symptoms  they  induce  and  their  physical 
appearance  depend  upon  their  situation,  and  will  be  described  in 
the  appropriate  chapters. 

Treatment. — Papillomata  may  be  removed  by  excision,  ligature, 


248  MANUAL   OF   SURGERY  chap. 

cauterisation,  etc.      The  means  employed  varies  with  the  situation 
of  the  growth. 

ADENOMATA 

Varieties. — Adenomata  are  racemose  or  tubular,  according  to 
the  variety  of  glands  they  mimic. 

The  racemose  or  aeinous  adenoma. — Racemose  adenoma  is 


Fig.  58. — Villous  tumour  of  the  bladder  (Bland  Sutton). 

common  in  the  breast.  Gland  tissue  is  also  met  with  in  the  mixed 
tumours  of  the  parotid  and  testicle.  Adenomata  are  sometimes 
met  with  in  the  liver,  and  some  enlargements  of  the  thyroid  gland 
may  be  considered  as  adenomata.  For  sebaceous  adenoma,  see 
p.  263. 

Morbid  anatomy. — The  racemose  adenoma  is  an  imperfect 
representation  of  a  racemose  gland,  and  is  always  perfectly  distinct 
from  the  gland  in  which  it  grows ;  its  imperfect  ducts  do  not  open 
on  the  surface,  nor  is  the  tumour  capable  of  secreting  the  normal 
fluid.  A  pure  adenoma,  i.e.  a  tumour  perfectly  mimicking  the 
normal  gland,  is  of  extreme  rarity.     The  adenomata  are  structurally 


XI 


ADENOMATA 


249 


composed  of  a  stroma  or  basis  containing  slit-like,  epithelium-lined 
spaces,  and  modifications  in  one  or  both  of  these  elements  give  rise 
to  tumours  of  different  appearances  and  clinical  effects.  The  slit- 
like spaces  are  lined  with  one  or  more  layers  of  short  columnar  or 
cubical  epithelium,  and  contain  a  clear  serous  fluid  ;  they  may  be 
dilated  into  cysts,  and  these  may  contain  intracystic  growths. 
The  stroma  is  usually  composed  of  fibrous  tissue  (adeno-fibroma), 
or  may  be  sarcomatous   (adeno-sarcoma). 


^'^^l^fe 


Fig.  59. — Tubular  adenoma  of  the  breast  (Ziegler).     a,  longitudinal  section  of  dilated  and 
branching  tubules  ;  b^  cross  section  of  tubules  ;  c,  stroma. 


Clinical  characters. — Adenomata  are  firm,  elastic,  slowly-growing, 
encapsuled  tumours,  and  may  attain  a  very  large  size.  If  the 
stroma  is  sarcomatous  the  tumour  will  grow  more  quickly  and 
assume  malignant  characters. 

The  reader  is  referred  to  the  chapter  on  Diseases  of  the  Breast 
(vol.  iii.)  for  further  information  regarding  these  tumours. 

Treatment — Thorough  removal  by  the  knife. 

Tubular  adenoma. — Tubular  adenomata  grow  from  mucous 
membranes.  The  best  example  is  the  mucous  polypus  of  tha 
rectum.     Tubular  adenomata  are  pedunculated  and  consist  of  con- 


250 


MANUAL  OF   SURGERY 


CHAP. 


nective   tissue  covered  with  mucous  membranCj   containing  many 
columnar  spaces  lined  by  epithelium. 

These  growths  are  especially  prone  to  become  cancerous. 


CARCINOMATA 

A  cancer  is  a  malignant  tumour  originating  in  and  com.posed  of 
epithelial  elements  enclosed  in  a  more  or  less  dense  alveolar  mesh- 
work  of  fibrous  tissue.     It  gradually  invades  the  adjacent  structures, 


(.  ^-^^ — o 


Fig.  60. — Scirrhous  carcinoma  of  the  breast  (Ziegler).     a,  stroma  ;  h,  loculi  filled  with  epithelium 
cells  ;  c,  isolated  cancer  cells  ;  d,  blood-vessel ;  e,  cellular  infiltration  of  the  stroma. 

spreading  by  means  of  the  lymph-paths,  and  in  most  forms  gives 
rise  to  secondary  growths  in  the  neighbouring  lymphatic  glands, 
and  sometimes  in  the  viscera  and  other  parts  of  the  body. 

Cancer  is  essentially  a  growth  of  the  latter  half  of  life,  but  may 
occasionally  occur  in  young  people  or  even  infants  ;  it  never  under- 
goes arrest  or  spontaneous  cure,  and  although  its  growth  may  be 
(but  rarely  is)  extremely  slow,  it  ends  by  causing  death. 

General  structur-al  anatomy. — The  epithelium  cells  of  a 
cancerous  growth  are  atypical  reproductions  of  the  cells  from  which 
they  spring,  and  hence  differ  in  shape  and  size  in  the  different 
forms.     They  are  loosely  massed  together  in  the  alveolar  spaces  of 


XI 


CARCINOMATA 


251 


the  stroma,  but  do  not,  as  in  the  adenomata,  form  a  definite  lining 
to  the  wall.  It  has  been  shown  by  many  observers  that  contained 
in  the  cells,  in  some  cases,  are  the  "  cancer-bodies,"  already  referred 
to  at  p.  225,  the  precise  nature  and  origin  of  which  is  at  present 
doubtful.  These  bodies,  when  present,  are  most  numerous  in  the 
region  of  acti\e  growth,  and  cannot  be  demonstrated  in  areas  of 
degeneration,  they  themselves  having  shared  in  the  process.  All 
cancers  are  pervaded  by  a  more  or  less  definite  and  abundant 
fibrous  stroma  arranged  in  alveoli  which  communicate  with  one 
another. 

In  the  rapidly-growing  cancers  the  stroma  is  scanty,  highly 
vascular,  contains  numerous  small  round  cells,  and  encloses  large 
alveolar  spaces,  while  the  hard,  comparatively  slowly-growing  forms 
have  an  abundant  and  dense  fibrous  stroma ;  the  epitheliomata 
have  very  little  or  none.  The  vessels  and  lymphatics  run  in  the 
fibrous  network. 

Cancers  do  not  possess  any  capsule,  but  at  the  advancing  edge 
the  tissues  are  infiltrated  with  round  cells  due  to  irritation  ;  these, 
developing  into  connective  tissue,  form  the  stroma,  the  cancer  cells 
spreading  into  it. 

Invasion  of  the  tissues  by  the  epithehum  cells  is  the  leading 
characteristic  of  carcinomata,  and  is  an  important  feature  dis- 
tinguishing them  from  adenomata 
or  paplllomata,  which  are  perfectly 
innocent  tumours  largely  composed 
of  epithelial  elements.  It  is  sup- 
posed by  some  that  the  invasion  of 
the  tissues  is  favoured  by  the  general 
laxity  and  loss  of  resistance  occur- 
ring in  advancing  life ;  but  that  this 
has  any  appreciable  influence  is 
more  than  doubtful,  for  we  must 
remember  that  invasion  is  not  con- 
fined to  cancers  of  solid  organs,  but 
occurs  equally  in  cancer  of  the  skin 
and  mucous  surfaces  where — if  re- 
sistance or  its  loss  played  an  im- 
portant part — invasion  would  be  less 
probable  than  would  the  heaping-up  of  proliferated  cells  on  the 
surface  (see  p.  229). 

Secondary  deposits. — Cancer  spreads  by  the  lymphatics,  infect- 
ing  the  walls   of  the  vessels  and  producing  secondary  involvement 


^.-^ 


Fig.  61. — Cancerous  embolus  in  a  hepatic 
capillan-  (Ziegler). 


252  MANUAL  OF  SURGERY  chap. 

of  the  glands.  Cancerous  emboli  may  also  be  carried  by  the 
lymph-stream  to  the  general  circulation  or  may  enter  it  directly 
through  the  vessels,  and  hence  secondary  deposits  may  occur  in 
the  viscera  and  distant  parts,  especially  in  the  liver  (Fig.  6i,  p.  251) 
and  lungs.  All  forms  of  cancer  do  not  show  the  same  reproductive 
tendency,  and  in  rodent  cancer  secondary  growths  are  unknown. 

The  secondary  deposits  are  facsimile  reproductions  of  the 
primary  growth,  undergo  the  same  degenerative  changes,  and  may 
themselves  act  as  centres  of  further  infection. 

Degenerative  changes  occur  more  quickly  and  are  more  wide- 
spread in  cancers  of  rapid  growth.  Fatty  degeneration  is  very 
common,  calcification  equally  rare.  Colloid  and  mucoid  changes, 
sometimes  resulting  in  the  formation  of  cysts,  may  occur. 

The  soft,  highly  -  vascular  carcinomata  may  be  the  seat  of 
haemorrhages. 

Varieties  of  cancer. — Normal  epithelium  may  be  divided 
according  to  its  function  into  the  glandular  or  secreting  and  the 
protective,  and  either  may  be  the  starting-point  of  cancer.  Cancers 
may  be  thus  classified  :— 

Glandular  carcinomata — 

Hard  or  scirrhus  cancer. 
Soft  or  encephaloid  cancer. 
Villous  cancer. 
Thyroid  cancer. 

Epitheliomata — 

Squamous  epithelioma. 
Columnar  epithelioma. 
Rodent  cancer. 

Colloid  cancer  is  the  term  applied  to  those  forms  which  have 
undergone  colloid  degeneration ;  such  a  change  is  almost  confined 
to  the  glandular  carcinomata,  and  is  most  frequently  seen  in  cancer 
of  the  abdominal  viscera  and  sometimes  in  the  breast.  Colloid 
degeneration  of  epithelioma  is  very  rare. 

General  treatment  of  cancer. — The  treatment  of  cancer  as 
it  occurs  in  different  parts  of  the  body  will  be  discussed  in  the 
appropriate  chapters.  In  this  place  it  will  be  sufficient  to  say  that 
at  present  removal  by  the  knife  at  as  early  a  date  as  possible  is  the 
only  means  at  our  disposal. 

Such  removal  must  be  sufficiently  wide  to  ensure  complete  ex- 
cision of  the  disease,  and  should  the  glands  be  involved,  they  must 
be  included. 

As  a  general  rule,  it  may  be  stated  that  no  operation  should  be 


XI  GLANDULAR   CARCINOMATA  253 

undertaken  unless  the  surgeon  can,  so  far  as  he  is  able  to  judge, 
absolutely  remove  the  whole  disease ;  yet  in  some  cases,  e.g.  the 
tongue,  it  is  quite  justifiable  and  right  to  remove  the  local  disease 
in  order  to  ease  the  patient's  sufferings,  even  when  it  is  clear  that 
the  spread  of  the  growth  cannot  be  checked.  If,  after  operation, 
secondary  growths  make  their  appearance,  they  must  be  treated  by 
operation,  provided  their  situation  admits  of  such  being  undertaken. 
The  treatment  of  cancer  by  caustics,  drugs,  etc.  need  only  be 
mentioned  to  be  condemned.  Attempts  have  been  made  of  late 
to  produce  a  curative  serum  from  cultivations  of  the  erysipelas 
organism  and  its  toxines,  but  so  far  as  clinical  experience  goes  up  to 
the  present  no  reliable  curative  results  have  been  obtained,  nor  has 
any  decided  benefit  been  shown  to  accrue,  although  local  necrosis 
has  ensued.  This  treatment  was  suggested  in  view  of  the  clinical 
observation  that  cancerous  growths  have  been  occasionally  apparently 
cured  by  an  attack  of  erysipelas.  Coley's  fluid  is  a  combination  of 
the  toxines  of  streptococcus  erysipelatis  and  bacillus  prodigiosus. 
The  dose  of  the  preparation  begins  with  half  a  minim  and  may  be 
gradually  increased.  The  injections  are  made  into  the  substance  of 
the  tumour.  Removal  of  the  ovaries  has  been  followed  by  atrophy 
of  incurable  cancer  of  the  breast,  but  how  this  is  occasioned  and  the 
value  of  the  procedure  are  unknov:n  (see  chap.  xxx.  vol.  iii.). 

GLANDULAR    CARCINOMATA 

The  difference  between  these  two  forms  lies  merely  in  the 
relative  proportion  of  cells  and  fibrous  stroma,  their  density 
depending  upon  the  amount  of  the  latter.  The  softer  the  tumour 
and  the  greater  its  vascularity,  the  more  rapid  is  its  growth  and  the 
more  evident  are  its  malignant  tendencies.  All  gradations  may  be 
met  with  between  a  dense  and  hard  scirrhus  and  the  softest  and 
most  rapidly  growing  encephaloid.  For  clinical  purposes  it  \n411  be 
convenient  to  describe  the  characters  of  the  hard  and  soft  varieties 
separately. 

Hard  glandular  cancer  or  scirrhus  is  chiefly  met  with 
in  the  breast,  but  may  also  occur  in  the  pancreas,  prostate,  skin, 
or  at  the  pylorus.  It  usually  occurs  after  the  age  of  forty, 
sometimes  earher.  In  most  cases  the  growth  is  comparatively  slow 
and  degeneration  of  the  cells  occurs  early,  probably  on  account  of 
the  relative  poorness  of  the  blood  supply.  Sometimes  this  form  of 
cancer  of  the  breast  may  take  many  years  to  grow,  or  remain 
apparently    quiescent    {atrophic   scirrhus).     At  first   the   tumour  is 


254 


MANUAL   OF   SURGERY 


CHAP, 


:^ 


more  or  less  circumscribed,  of  stony  density  but  freely  movable ; 
later  on  it  becomes  adherent  to  the  deep  and  superficial  structures 
and  may  infiltrate  the  skin  and  fungate  on  the  surface,  or  give  rise 

to  a  deep,  unhealthy,  indurated 
ulcer  (Fig.  62)  covered  by  fatty 
granulations,  or  showing  a 
tendency  to  slough.  As  the 
skin  is  approached  the  con- 
traction of  the  fibrous  elements 
of  the  growth  causes  dimpling. 
The  lymphatic  glands  are  in- 
volved and  secondary  tumours 
of  softer  nature  and  more  rapid 
growth  appear  in  distant  organs. 
On  section,  a  typical  scir- 
rhus  has  the  appearance  of  an 
unripe  pear  or  turnip ;  it  is 
very  dense,  grayish  -  white  in 
colour,  and  flecked  with  streaks 
and  spots  of  yellow  due  to  fatty 
degeneration.  Radiating  from 
the  margin  are  fine  processes 
and  grayish  -  white  lines  indicating  the  direction  in  which  the 
growth  is  spreading.  The  surface  of  a  section  does  not  bulge  but 
is  rather  cupped,  and  when  scraped  yields  a  milky  juice  which  is 
rich  in  epithelial  cells. 

Soft  glandular  cancer  or  encephaloid  is  rare,  and  chiefly 
affects  the  breast,  testes,  or  liver.  The  component  cells  may  be  very 
large ;  the  fibrous  stroma  is  scanty,  highly  vascular,  and  encloses  large 
alveolar  spaces.  Growth  is  very  rapid  and  as  the  skin  is  invaded 
the  tumour  fungates  on  the  surface,  giving  rise  to  a  large  sloughy 
mass  which  may  bleed  profusely.  Clinically  and  macroscopically 
these  growths  closely  resemble  the  soft  sarcomata,  the  microscope 
being  necessary  for  diagnosis.      They  are  highly  malignant. 

On  section  the  cut  surface  bulges,  and  the  tumour  is  of  a  pink 
colour  and  brain-like  appearance.  It  is  very  soft  and  sometimes 
pulpy ;  large  hcemorrhages  may  be  present  and  these  may  have 
broken  down  the  tumour  tissue  into  a  diftluent  mass. 

Duct  or  villous  cancer  is  a  rare  form  met  with  in  the  breast. 
It  is  characterised  by  the  distension  of  the  ducts  into  cysts  containing 
papillary  growths,  the  epithelium  of  which  proliferates  and  invading 
the  walls  of  the  ducts  grows  into  the  breast  substance.     The  tumour 


Fig.  62. — Ulcerating  scirrhus  oi  the  breast,  with 
invasion  of  the  surrounding  parts  (Follin). 


XI 


THE   EPITHELIOMATA 


255 


clinically  runs  much  the  same  course  as  other  glandular  cancers, 
and  is  moderately  soft.  It  is  much  less  malignant  than  the  other 
forms,  and  the  glands  are  involved  late. 

Thyroid  cancer  is  a  very  rare  form  met  with  in  the  thyroid 
gland,  mimicking  that  organ  in  its  structure  and  reproducing 
similar  tumours  as  secondary  deposits  (see  chap.  xiii.  vol.  iii.). 

THE    EPITHELIOMATA 

Squamous    epithelioma   is   often  traceable    to    some    long 


S^gA^^^J^ 


\i 

Fig.  63. — Section  from  an  epithelioma  of  the  skin  (X20),  (Ziegler).  a,  epidermis ;  <5,  corium  ;  c, 
subcutaneous  areolar  tissue  ;  d,  sebaceous  gland  ;  e,  hair  follicle  ;  y,  cancerous  ingrowths  of 
the  epidermis;  g;  deep-set  cancerous  cell  groups;  A,  proliferating  fibrous  tissue;  z  (above), 
cancer  cell  nest  or  epidermic  globe  ;  t  (below),  sweat  gland. 

continued  irritation  and  usually  occurs  at  parts  where  mechanical 
irritation  is  most  frequent.  It  is  common  at  the  sides  of  the 
tongue,  at  the  muco-cutaneous  margin  of  the  lips  (usually  the 
lower),  in  scars,  and  about  the  vulva,  glans  penis,  etc. 

Morbid  anatomy. — The  cells  are  large  and  flattened  with  a 
definite  nucleus,  or  sometimes  more  than  one  owing  to  endogenous 
grov;th.  They  grow  into  the  lymph  spaces  as  solid  anastomosing 
cylirders  from  which  they  may  sometimes  be  squeezed  out  like 
the   secretion   in   a   comedo.     As  growth  proceeds  the  cells  pass 


6  MANUAL  OF  SURGERY  chap. 


along  the  lymphatics  and  affect  the  glands,  but  secondary  deposits 
elsewhere  are  of  the  greatest  rarity.  Through  mutual  compression 
the  cells  are  flattened,  and  at  the  seats  of  most  rapid  growth 
"  bird's-nest "  collections  are  formed.  This  arrangement,  w^hich 
may  also  be  seen  in  papillomata,  is  due  to  rapid  central  proliferation, 
the  peripheral  cells  being  compressed  while  the  central  ones  are 
often  fatty ;  hence  the  appearance  of  these  nests  is  somewhat  that 
of  an  onion  in  section  (Fig.  63,  /,  p.  255).  The  stroma  is  never  a 
marked  feature  of  the  growth ;  it  is  formed  by  the  connective 
elements  of  the  tissues  among  which  the  epithelium  cells  penetrate. 
Owing  to  irritation  the  tissues  are  infiltrated  with  numerous,  small, 
round  cells.  Growth  towards  the  surface  gives  rise  to  a  circum- 
scribed, fungous  mass  raised  above  the  level  of  the  surrounding 
parts  and  distinctly  indurated.  In  such  cases  the  cells  may  rapidly 
break  down  and  an  ulcer  result,  or  they  may  lose  water  by  evapora- 
tion and  become  dense  and  horny  like  the  surface  of  a  wart 
(cornified  or  warty  epithelioma). 

Clinical  ehapaeters. — Epithelioma  may  begin  as  an  ulcer,  a 
persistent  fissure,  or  a  small  tubercle  which  soon  ulcerates.  There 
is  always  marked  induration  and  the  glands  are  quickly  involved. 
Pain  is  never  very  severe  and  often  absent.  An  epitheliomatous 
ulcer,  when  quite  small,  may  be  covered  with  a  scab,  but  as  it 
increases  in  size  this  is  no  longer  possible,  and  the  floor,  which  is 
sloughy  and  may  be  covered  with  fatty,  unhealthy  granulations, 
becomes  exposed;  the  edges  are  raised,  everted,  sometimes 
undermined,  and  always  indurated.  As  ulceration  extends,  the 
soft  structures  are  destroyed  and  vessels  may  be  opened ;  the  dense 
structures  are  usually  respected.  Ulceration  on  the  surface  may 
keep  pace  w^ith  growth  in  the  deeper  parts  so  that  no  definite  tumour 
is  ever  formed,  the  disease  assuming  the  characters  of  a  malignant 
ulcer  rather  than  of  tumour  growth. 

Columnar  epithelioma  is  not  a  common  growth,  but  may 
originate  in  the  columnar  epithelium  of  the  stomach,  intestines, 
rectum,  or  uterus,  and  is  sometimes  found  growing  from  the  lining 
membrane  of  the  antrum. 

Morbid  anatomy. — On  microscopic  examination  these  growths 
resemble  the  tubular  adenomata,  being  composed  of  columnar  cells 
arranged  in  columns  and  enclosing  gland-like  spaces,  or  completely 
filling  the  lumen  of  the  tubular  stroma.  The  cells,  unlike  those  of 
adenomata,  spread  beyond  the  tubular  structures  and  infiltrate  the 
surrounding  tissues.  Secondary  deposits  are  common  in  this  form 
of  epithelioma. 


XI  THE   EPITHELIOMATA  257 

Clinical  characters. — Columnar  cancer,  when  growing  in  tlie 
gut,  tends  to  completely  encircle  it  and  to  spread  to  the  surround- 
ing parts.  It  is  clearly  demarcated  to  the  naked  eye,  and  has  a 
raised,  usually  rounded  and  dense  margin,  but  is  ulcerated  in  the 
centre.  The  mass  grows  more  slowly  than  squamous  cancer,  but 
will  prove  equally  fatal. 

Rodent  cancer  or  rodent  ulcer. — Rodent  ulcer  is  an 
epitheliomatous  cancer  of  slight  malignancy  often  remaining 
stationary  for  many  years.  It  is  characterised  by  local  persistence, 
but  never  becomes  disseminated  or  directly  affects  the  general 
health.  It  is  very  rare  before  the  thirtieth,  and  most  usually  begins 
after  the  fiftieth  year. 

Distribution. — Rodent  cancer  always  begins  in  the  skin  ;  its 
origin  is  attributed  by  different  observers  to  the  hair-follicles,  sweat- 
ducts,  or  sebaceous  glands,  and  it  may  probably  originate  in  any  of 
these  structures.  Any  part  of  the  skin  may  be  affected  but  rodent 
ulcer  is  far  more  frequently  seen  on  the  lower  eyelid  or  side  of  the 
nose  than  in  all  other  parts  put  together. 

Morbid  anatomy. — Microscopically  a  rodent  cancer  is  found  to 
consist  of  columns  of  small  cells  of  an  epithelial  character  contain- 
ing oval  nuclei  embedded  in  an  imperfect  connective-tissue  stroma. 
The  cells  never  form  "  nests  "  as  in  squamous  cancer,  and  are  very 
delicate,  so  that  their  outline  is  sometimes  difficult  to  distinguish. 
They  may  be  vacuolated,  but  do  not  form  a  fungous  or  warty  mass, 
such  as  is  seen  in  squamous  cancer. 

Clinical  characters. — Rodent  ulcer  begins  as  a  pimple,  or  flat- 
tened, brownish  tubercle,  which  ulcerates.  When  quite  small  the 
ulcer  is  covered  with  a  hard,  dry  scab,  removal  of  which  exposes  a 
deep,  punched-out,  crater- like,  florid  surface.  The  scab  quickly 
re-forms.  The  ulcer  may  remain  in  this  condition  for  years,  or  m.ay 
gradually  increase  in  area  until  the  most  extensive  damage  is  in- 
flicted. The  surface  of  the  ulcer  is  grayish-red  in  colour,  smooth, 
glazed,  destitute  of  granulations,  and  secretes  a  very  scanty,  thin, 
watery  discharge.  The  centre  is  depressed,  the  margin  slightly 
raised  but  free  from  induration. 

The  tis^es  are  gradually  destroyed  irrespective  of  their  nature 
or  density,  and  in  bad  cases  the  bones  at  the  base  of  the  skull  may 
be  destroyed  and  the  brain  exposed.  It  is  characteristic  of  rodent 
ulcer  that  it  spares  nothing,  spreading,  however,  in  superficial  extent 
rather  than  in  depth.  The  glands  are  not  involved,  and  secondary 
deposits  do  not  occur.  The  course  is  painless  and  unattended  by 
constitutional  cachexia,  the  patient  usually  dying  of  some  other 
VOL.  I  S 


258  MANUAL  OF   SURGERY  chap. 

disease.  In  some  cases  epithelium  may  grow  from  the  margin  of 
the  skin  and  cause  partial  healing,  but  this  is  only  temporary  and 
is  never  sound  or  accompanied  by  cicatrisation. 

Treatment. — Complete  and  free  removal  of  the  ulcer  is  the 
only  treatment,  and,  if  efficiently  performed,  is  followed  by  a  per- 
manent cure.  If  the  disease  be  too  extensive  for  this  nothing  can 
be  done  beyond  keeping  the  surface  clean,  or  attempting  to  arrest 
the  progress  of  the  ulceration  by  the  application  of  caustic  pastes 
or  the  strong  mineral  acids. 


Class  5. — Congenital  Tumours 

teratomata 

A  teratoma  is  a  congenital  tumour  composed  of  all  kinds  of 
tissue  in  a  more  or  less  imperfect  state  of  development  and  fre- 
quently mixed  together  in  a  confused  mass.  Some  of  these  tumours 
are  instances  of  foetal  inclusion,  a  parasitic  and  imperfectly  developed 
foetus  being  grafted  on,  or  included  in  the  body  of  the  living  and 
developed  twin  ;  in  other  cases  the  teratoma  is  due  to  imperfect 
differentiation  of  the  tissues  of  a  single  foetus.  Teratomata  may 
attain  an  enormous  size  and  are  met  with  about  the  head  or  neck, 
or  internally,  usually  in  connection  with  the  generative  organs.  The 
most  common  form  is  the  congenital  sacral  tumour  (see  p.  316). 

DERMOID    TUMOURS 

A  dermoid  is  a  tumour  of  congenital  origin  containing  skin  or 
mucous  memibrane  and  their  appendages  or  modifications.  These 
tumours  are  usually  met  with  in  the  young,  but  from  their  position 
or  size  may  not  attract  attention  for  some  years. 

Varieties  and  distribution. — Sequestration  dermoids  arise 
from  the  inclusion  among  the  mature  tissues  of  detached  portions  of 
epiblast  at  the  points  of  coalescence  of  the  skin  during  embryonic 
life.  Sacral  dermoids,  scrotal  dermoids,  and  those  along  the 
middle  line  of  the  trunk  arise  at  the  line  of  union  of  the  two  lateral 
halves  of  the  body.  During  the  development  of  the  face  epiblastic 
rudiments  may  be  shut  off  at  the  naso-orbital  fissure,  or  along  the 
line  of  junction  of  the  maxillary  plates,  or  that  of  the  superior  plate 
with  the  fronto  -  nasal  process  (see  Development  of  the  Face, 
p  278).  Dermoids  are  most  common  at  the  outer  angle  of 
the  eye  but  sometimes  occur  at  the  inner  angle  or  in  the  naso- 


XI 


DERMOID   TUMOURS 


259 


facial  sulcus.  Tliey  ^e  also  met  with  in  the  palate,  at  the  root  of 
the  nose,  and  in  connection  with  the  ear.  At  an  early  period  of 
devefopment  the  scalp  and  dura  mater  are  in  contact,  but  are 
eventually  separated  by  the  growth  of  the  bony  walls  between  them  ; 
if,  daring  this  process,  a  portion  of  the  skin  remains  included,  a 
dermoid  tumour  attached  to  the  dura  mater  by  a  fibrous  pedicle 
and  projecting  through  a  hole  in  the  vertex  will  result,  owing  to 
the  incomplete  development  (Fig.  64). 

Tubulo-dermoids  is  the  name  given  by  Bland  Sutton  to  dermoid 
tumours  arising  in  connection  with  obsolete  canals  and  clefts.  Thus, 
dermoids  of  the  neck  may  arise  from  epiblastic  inclusion  in  the  line  of 


Fig.  64. — Dermoid  of  the  scalp  connected  by  a  pedicle  with  the  dura  mater  (Bland  Sutton, 
from  a  specimen  in  the  museum  of  the  Middlesex  Hospital). 

the  branchial  clefts.  Lingual  dermoids  arise  in  connection  with 
the  linguo-hyal  duct ;  and  occasionally  a  dermoid  is  met  with  behind 
the  rectum  in  association  with  the  post-anal  duct,  which  may  also 
be  the  origin  of  the  congenital  sacral  tumour. 

Ovapian  dermoids  (see  chap.  xxix.  vol.  iii.). 

Morbid  anatomy. — The  morbid  anatomy  of  dermoids  varies 
somewhat  with  the  situation  in  which  they  occur,  and  will  be  referred 
to  in  the  appropriate  sections. 

They  all  consist  of  a  fibrous  wall  which  is  more  or  less  com- 
pletely lined  with  imperfect  skin  or  mucous  membrane  covered  by 
several  layers  of  epithelium  cells.  Sebaceous  and  sweat-glands  are 
both  present  and  the  cyst  is  filled  with  sebaceous  material  and  shed 
epithelium    scales,   cholesterine,    and    hair.     The   amount   of    hair 


26o  MANUAL   OF   SURGERY  chap. 

varies  :  ovarian  dermoids  contain  the  most  and  longest,  sequestration 
dermoids  usually  only  a  few  short,  fine  hairs.  When  the  tumours 
are  old  the  hair  may  fall  or  turn  gray.  The  sebaceous  glands  are 
often  much  larger  and  more  numerous  than  in  normal  skin.  Teeth 
are  common  in  ovarian  dermoids  but  are  not  met  with  in  those 
due  to  sequestration  of  epiblastic  elements.  Sutton  has  described 
a  dermoid  in  which  he  found  an  imperfect  mamma. 

Clinical  characters. — Dermoid  tumours  are  quite  innocent, 
appear  at  an  early  age,  and  grow  slowly.  A  dermoid  usually  forms 
a  more  or  less  rounded,  elastic  tumour  resembUng  a  sebaceous  cyst. 
The  situation  of  the  tumour  is  usually  an  important  element  in 
the  diagnosis. 

Treatment. — Dermoids  should  be  removed  unless  their  situa- 
tion precludes  the  justifiability  of  operative  interference. 

CVSTS 

Definition. — A  cyst  is  a  sac  of  fibrous  tissue  containing  fluid  or 
soft  pultaceous  matter.  The  term  is  a  chnical  one  but  is  not  patho- 
logical, embracing  as  it  does  many  conditions  of  very  varying  nature 
and  mode  of  formation,  some  of  which  are  tumours  in  the  proper 
sense  of  the  term  while  others  are  not. 

General  morbid  anatomy. — The  wall  of  any  cyst  is  com- 
posed of  fibrous  tissue  elements  which  may  be  of  new  formation,  or 
may  consist  of  the  fibrous  wall  of  the  duct  or  acinus  to  dilatation  of 
which  the  formation  of  the  cyst  is  due.  In  any  case  the  wall  is 
strengthened  by  fibrous  tissue  of  new  formation  as  the  result  of 
irritation,  and  hence  it  may  become  much  increased  in  thickness. 
The  walls  of  some  cysts,  however,  are  extremely  thin.  If  a  cyst  has 
arisen  from  dilatation  of  a  tube  containing  muscular  tissue,  traces  of 
it  may  be  found  in  the  wall  but  the  greater  part  will  have  undergone 
atrophy.  Externally  the  wall  is  connected  to  the  surrounding  parts 
by  delicate  areolar  tissue  so  that  the  cyst  may  be  easily  enucleated ; 
but  in  some  cases — especially  if  inflammation  has  been  excited — 
the  wall  is  very  adherent.  Cysts  arising  in  connection  with  a  space 
lined  with  epithelium  or  endothelium  are  themselves  similarly  lined, 
unless  the  epithelium  has  undergone  atrophy  and  destruction  from 
pressure  ;  otherwise,  the  interior  is  destitute  of  cellular  lining.  The 
wall  of  a  cyst  may  enclose  a  single  loculus,  or  the  interior  may  be 
traversed  by  bands  or  septa  dividing  it  up  into  numerous  loculi 
which  communicate  with  each  other.  A  cyst  is  said  to  be  cojnpoimd 
when  it  consists  of  numerous  loculi  which  do  not  communicate,  e.g. 


XI  CYSTS  261 

some  ovarian  tumours  and  cystic  hygroma.  In  such  cases  some  of 
the  loculi  may  eventually  communicate  by  giving  way  of  the  wall 
dividing  them.  Papillomatous  and  solid  outgrowths  of  the  wall 
may  project  into  the  cavity  of  the  cyst,  as  in  some  cases  of  ovarian 
and  mammary  tumour  {Proliferous  cyst). 

The  contents  of  a  cyst  vary  with  its  origin ;  but,  whatever  fluid 
it  may  originally  contain,  this  tends  with  time  to  become  more  dense 
and  inspissated  and  to  lose  its  original  character.  The  contents 
may  be  mixed  with  inflammatory  products,  should  the  wall  have 
been  the  seat  of  such  a  change. 

The  size  of  cysts  varies  very  much ;  the  largest  are  met  with  in 
the  ovary.  Sometimes  growth  is  arrested  by  calcification  of  the  cyst 
wall  or  some  other  cause  according  to  the  nature  of  the  cyst.  The 
wall  may  inflame  and  suppuration  ensue. 

General  clinical  characters. — Cysts  are  perfectly  innocent. 
They  usually  grow  slowly  in  the  direction  of  least  resistance  and 
thus  may  send  long  processes  among  the  muscles,  etc.  A  cyst  forms 
a  rounded,  smooth,  tense,  elastic  tumour,  which,  when  superficial, 
may  be  translucent  if  the  contents  are  clear  and  the  walls  thin. 
There  is  no  pain  unless  a  nerve  be  pressed  upon,  and  the  symptoms 
are  due  to  mechanical  pressure  only.  If  deep-seated  or  very  tense, 
or  with  thick  calcareous  walls,  it  may  be  impossible  to  diagnose  a 
cyst  from  a  solid  tumour  without  puncture.  A  cyst  may  remain 
stationary  for  years,  and  may  gradually  get  somewhat  smaller  as  the 
fluid  contents  inspissate.  In  other  cases  it  may  undergo  spontane- 
ous cure  by  rupture  or  suppuration,  or  may  cause  serious  and  fatal 
results  from  its  position  or  size. 

General  treatment. — The  treatment  applicable  to  a  cyst  in 
any  given  region  will  be  indicated  in  the  proper  place ;  it  is  here 
sufficient  to  point  out  the  various  methods  of  treatment  which  are 
applicable  under  suitable  conditions. 

Simple  aspiration  is  a  temporary  means  only,  although  in  a  few 
instances  it  may  lead  to  permanent  cure.  Aspiration  and  injection 
with  iodine,  carbolic,  etc.,  is  useful  in  some  forms,  especially  hydro- 
cele of  the  tunica  vaginalis.  Subcutaneous  rupture  is  sometimes 
successful  in  curing  ganglion,  and  acupuncture  is  useful  in  hydrocele 
in  infants.  Ranulie  and  mucous  cysts  are  best  treated  by  removal 
of  a  portion  of  the  wall  and  destruction  of  the  epithelial  lining  by 
caustic. 

Excision,  when  possible,  is  the  best  method.  If  other  means 
fail,  and  excision  cannot  be  undertaken,  the  cyst  must  be  laid  open 
and  allowed  to  heal  by  granulation. 


2  62  MANUAL   OF   SURGERY  chap. 

Origin  and  varieties. — Cysts  are  classified  according  to  their 
methods  of  origin. 

(a)  Retention  eysts. — If  a  duct  which  opens  on  the  surface  of 

the  skin  or  mucous  membrane  becomes  obstructed  the  secretion 
will  accumulate  behind  it,  and  a  cyst  result.  The  obstruction  is 
usually  only  partial,  and  may  be  continuous  or  intermittent.  Such 
cysts  are  limited  by  the  distended  duct  or  acinus  wall  and  are  lined 
by  the  epithelium  common  to  the  part.  The  wall  is  increased  in 
thickness  by  new  fibrous  tissue.  The  contents  are  the  normal  secre- 
tion, which  in  old  cases  is  inspissated  and  altered  in  appearance,  and 
may  be  calcareous  or  fatty,  and  perhaps  mixed  with  inflammatory 
products. 

Retention  cysts  may  arise  in  connection  with  the  ducts,  acini 
or  tubules  of  the  breast,  pancreas  and  salivary  glands,  testicle, 
kidney,  liver,  and  sebaceous  or  Meibomian  glands. 

Retention  cysts  of  mucous  glands  are  chiefly  met  with  beneath 
the  mucous  membrane  of  the  mouth  and  lips,  and  in  the  canal  of 
the  cervix  uteri,  more  rarely  in  the  stomach  and  intestines. 

The  reader  is  referred  to  the  special  chapters  for  their  diagnosis 
and  treatment. 

Sebaceous  cysts  (syn.  atheromatous  cysts  or  wens). — A  sebaceous 
cyst  is  a  tumour  formed  by  the  accumulation  of  sebum  within  a 
fibrous  capsule  of  varying  thickness,  formed  by  the  distended  gland 
wall  and  new  fibrous  tissue.  Sometimes  the  duct  is  obhterated,  at 
others  it  is  patent ;  and  no  doubt  some  sebaceous  cysts  arise  in  con- 
nection with  sebaceous  glandular  elements  in  the  skin,  which,  from 
imperfect  development,  have  never  been  provided  with  an  excretory 
duct.  Sebaceous  cysts  usually  contain  a  cheesy  material  which  may 
undergo  decomposition,  soften,  and  become  extremely  offensive ;  in 
other  cases  it  gradually  escapes  through  the  minute  opening  on  the 
skin,  and  dries  upon  the  surface.  By  continued  escape  a  definite 
sebaceous  horn  may  result  and  attain  a  considerable  size  (Fig.  6^).  If 
the  cyst  wall  inflames,  it  becomes  adherent  to  the  surrounding  struc- 
tures, the  skin  becomes  thinned  and  ultimately  gives  way,  and  the 
purulent  and  cheesy  contents  are  evacuated.  In  such  an  event 
spontaneous  cure  may  result,  or  the  discharge  continue  for  a  long 
time ;  should  the  cavity  become  septic,  a  spreading  destructive 
inflammation  may  result,  and  a  foul  surface  makes  its  appearance, 
which  suggests  malignant  ulceration.  ^Malignant  disease  does  occa- 
sionally attack  the  epithelial  lining  of  sebaceous  cysts.  Sebaceous 
cysts  may  be  single  or  numerous,  and  are  commonly  met  with 
about  the  scalp.     They  are,  unless  inflamed,  quite  painless,"  of  slow 


XI 


CYSTS 


26 


growth,  rounded  in  outline,  and  movable  on  subjacent  parts  but 
attached  to  the  skin.  A  small  black  depression  or  pimple  may  indi- 
cate the  position  of  the  duct,  and  this  may  be  covered  over  with  a 
small  black  mass  of  extruded  and  dried  sebum. 

Sometimes  a  complex  tumour  is  met  with  composed  mainly  of 
overgrown  sebaceous  glands,  some  of  which  may  be  dilated  by  sebum 
(sebaceous  adenoma).  Such  a  tumour  may  inflame  and  ulcerate 
and  form  a  fungating  cancer-like  mass.  So-called  lipoma  nasi  con- 
sists largely  of  sebaceous  glands  (see  chap.  x.  vol.  iii.). 

Treatment. — Sebaceous  cysts  are  readily  removed  by  enucleation 


Fig.  65. — Sebaceous  tumours  in  scalp  and  horn  (Brj-ant). 

after  an  incision  has  been  made  over  them.  If  inflamed,  and  the 
skin  over  the  most  prominent  part  is  thinned  and  much  adherent  to 
the  tumour  this  may  be  removed  with  it.  Sometimes  an  inflamed 
cyst  cannot  be  completely  removed  and  it  is  then  necessary  to  lay 
it  freely  open,  evacuate  the  contents,  and  sharp-spoon  the  interior  of 
the  cyst.  If  any  part  of  the  secreting  surface  of  the  wall  be  left 
reaccumulation  of  the  sebaceous  matter  is  to  be  expected. 

(b)  Exudation  eysts. — Accumulation  of  fluid  in  closed  spaces 
having  no  excretory  duct,  in  lymphatic  spaces,  or  in  functionless 
canals,  gives  rise  to  an  exudation  cyst.  The  structure  is  similar  to 
that  of  a  retention  cyst  but  the  lining  of  the  wall  varies  with  the 
origin  of  the  cyst.      The  contents  are  clear  serum. 

Dilatation  of  the  lymph-spaces   results   in   the  form.ation  of  a 


264  MANUAL   OF   SURGERY  chap,  xi 

simple  serous  cyst  or  false  bursa.  Cystic  hygroma  is  formed  in 
this  way.  Bursal  cysts,  ganglion,  hydrocele,  and  Morrant  Baker's 
cysts  (arising,  as  diverticula,  from  synovial  membranes)  are  examples 
of  exudation  cysts  into  closed  serous  cavities.  Thyroid  cysts,  and 
those  of  the  ovar)-,  parovarium,  and  paroophoron,  some  forms  of  en- 
cysted hydrocele,  cysts  of  the  neck,  and  the  rare  cysts  of  the  urachus 
and  vitello-intestinal  duct,  belong  to  this  group,  in  which  meningo- 
celes are  also  included  by  some  writers. 

(c)  Extravasation  cysts. — Haemorrhage  into  the  tissues  or  into 
the  substance  of  a  tumour  or  closed  sac,  may  result  in  the  formation 
of  a  tumour  bounded  by  a  dense  fibrous  wall  and  containing  altered 
blood-clot  (haematoma,  haematocele). 

(d)  Implantation  cysts. — It  occasionally  happens  that,  as  the 
result  of  injury,  a  portion  of  the  superficial  tissues  is  driven  into  and 
remains  embedded  in  the  deeper  structures.  Should  this  continue 
to  grow  fluid  may  be  exuded  into  it,  and  thus  a  cyst  is  formed. 
Occasionally,  instead  of  a  cyst,  a  solid  tumour  having  the  histological 
characters  of  the  embedded  tissue,  results. 

(e)  Parasitic  cysts. — Cysts  due  to  the  presence  of  the  taenia 
echinococcus  or  hydatid  are  common,  and  are  described  in  chap, 
viii.  vol.  iil 

Cysticercus  cellulosae,  the  larval  form  of  taenia  solium,  is  occa- 
sionally met  with  in  man,  and  is  contained  in  a  small  thin-walled 
cyst.     It  chiefly  affects  the  muscles  (see  chap.  viii.  vol.  iii.). 


CHAPTER    XII 

Deformities 

Deformities  of  the  Spinal  Column 

SPINA  bifida 

Definition. — A  spina  bifida  is  a  congenital  gap  in  the  spinal  column 
through  which  some  of  the  contents  of  the  canal  bulge  and  give 
rise  to  a  tumour. 

Etiology. — The  primary  cause  of  spina  bifida  like  that  of  other 
congenital  deformities  is  unknown.  Whatever  the  cause  be.  it  acts 
in  most  cases  at  an  early  period  of  fcetal  life  and  prevents  a 
proper  dififerentiation  of  the  epiblastic  layers  from  which  the  cord  and 
cutaneous  structures  are  developed,  so  that  these  remain  in  contact, 
and  the  vertebral  laminae  are  undeveloped.  Spina  bifida  is  often 
associated  with  hydrocephalus  or  talipes,  and  in  the  cervical  region 
with  crania  bifida  or  anencephalous. 

Morbid  anatomy. — Spina  bifida  is  most  common  in  the  lumbo- 
sacral region  of  the  column,  rarest  in  the  dorsal  region,  and  in 
the  cervical  is  often  associated  with  crania  bifida.  In  extremely 
rare  instances  the  cleft  has  been  through  the  bodies,  the  tumour 
projecting  anteriorly.  Occasionally  only  one  vertebra  is  affected, 
but  usually  several  neural  arches  remain  undeveloped ;  the  gap  thus 
varies  in  size — a  matter  of  importance  in  reference  to  treatment. 

The  sae  or  tumour  is  centrally  situated  and  is  round  or  oval  in 
shape,  with  its  long  axis  parallel  with  that  of  the  column.  It  is 
usually  sessile  with  perhaps  slight  constriction  at  the  base,  but  in 
some  cases  (chiefly  those  of  simple  meningocele  with  a  small  cleft) 
it  is  pedunculated.  Usually  small  at  birth,  the  tumour  may  rapidly 
increase  and  attain  a  large  size  unless  it  bursts.     It  often  presents 


266  MANUAL   OF   SURGERY  chap. 

at  or  near  its  most  prominent  part  a  depression,  median  furrow,  or 
umbilicus,  indicating  the  point  at  which  the  cord  and  nerves  blend 
with  the  sac-wall,  which  in  consequence  yields  less  readily  to  the 
pressure  of  the  cerebro-spinal  fluid  (Fig.  66).  The  interior  of  the 
sac  may  be  loculated,  and  its  contour  show  furrows  and  lobulations 
indicative  of  such  a  condition ;  these  loculi  usually  communicate 
with  one  another  by  small  rounded  openings. 

Covering's. — Normal  skin  very  rarely  covers  the  entire  tumour ; 
it  is  usually  only  present  at  the  base  and  ends  abruptly  or  gradually 
in  a  more  or  less  membranous  tissue  which  completes  the  covering. 
At  the  summit  this  membranous  area  may  have  a  raw  appearance, 
and  is  very  liable  to  rupture  or  slough.  In  those  cases  in  which 
skin  forms  a  complete  covering  it  is  usually  smooth,  shiny,  and  scar- 
like at  the  summit  of  the  sac,  where  it  may  slough.  The  dura 
mater  is  blended  with  the  superficial  covering,  and  the  arachnoid 
passes  into  the  base  of  the  neck  of  the  sac,  and,  in  nearly  all  cases, 
is  then  lost. 

Contents. — The  sac  may  or  may  not  contain  nervous  tissue, 
according  to  the  variety  of  spina  bifida.  The  fluid  is  ordinary 
cerebro-spinal  fluid,  clear,  colourless,  of  low  specific  gravity,  usually 
about  1007  ;  it  is  faintly  alkaline,  and  contains  a  trace  of  albumen, 
a  copper-reducing  substance,  and  about  i  per  cent  of  solid  matter 
consisting  chiefly  of  sodium  chloride. 

Varieties. — Simple  spinal  mening"oeele. — About  12  per  cent 
of  all  cases  belong  to  this  form  in  which  the  tumour  contains  fluid 
only,  the  cord  and  nerves  lying  within  the  canal.  The  cleft  is 
usually  small  and  in  some  cases  there  may  be  none,  the  protrusion 
then  occurring  between  the  adjacent  laminae.  The  tumour  is  not 
infrequently  pedunculated,  and  is  often  covered  with  normal  skin. 
Spontaneous  cure  may  result,  and  treatment  is  more  successful  and 
less  fraught  with  danger  than  in  any  other  form.  This  form  is  alone 
suited  to  treatment  by  excision. 

Mening^o-myeloeele  occurs  in  about  86  per  cent  of  all  cases. 
The  cord  or  nerves  of  the  cauda  equina  enter  the  sac,  and  blending 
with  its  wall  may  be  almost  indistinguishable  from  it.  The  nerves 
cross  the  sac  in  order  to  reach  their  foramina  of  exit  from  the  spinal 
canal.  Where  the  cord  blends  with  the  sac  a  depression  is  usually 
present,  as  mentioned  above. 

Syring-o-myeloeele  makes  up  the  remaining  2  per  cent  of  spina 
bifida.  This  very  rare  form  is  due  to  dilatation  of  the  central  canal 
of  the  cord.  The  posterior  part  of  the  cord  and  its  nerves  He  in 
the  sac,  the  latter  being  intimately  blended  with  it. 


XII 


SPINA    EIFIDA 


267 


Diagnosis. — The  general  signs,  appearances,  and  situation  of 
the  tumour  have  been  already  described.    The  margins  of  the  cleft  and 
the  continuity  of  the  tumour  with  the  spinal  canal  may  be  made  out  by 
examination  of  its  base.     Fluctua- 
tion is  present,  and  the  tenseness 
of   the   tumour,    which    is    partly 
reducible,     varies     with     circum- 
stances.      If   the    child    is    held 
upright  the  tension  is  increased, 
but  is  diminished  if  the  pelvis  is 
raised ;  tension  is  also  increased 
during    strong    expiration,    as    in 
crying,  but  is  diminished  in  forced 
inspiration.       In   some    cases    an 
impulse  may  be  obtained  at  the 


anterior  fontanelle  when  pressure    \^ 
is  exerted  on  the  tumour. 

Course  and  prognosis. — 
The  prognosis  of  spina  bitida  is 
bad ;  most  cases  gradually  in- 
crease in  size,  and  eventually 
rupture.  Spontaneous  cure  occa- 
sionally results,  especially  in 
pedunculated  spinal  meningocele  ; 
in  such  cases  the  small  opening 
in  the  canal  closes,  the  cyst  is 
cut  off,  and  constitutes  one  form 
of  false  spina  bifida.  Death  may 
occur  from  convulsions,  rupture  and  sloughing  of  the  sac,  menin- 
gitis, or  marasmus. 

The  prognosis  is  naturally  influenced  by  the  degree  and  situa- 
tion of  the  deformity,  the  state  of  the  coverings  of  the  sac,  and  the 
general  health  of  the  child.      In  rare  cases  adult  life  is  reached. 

Treatment. — Unless  the  circumstances  of  the  case  demand 
more  immediate  treatment,  nothing  of  a  curative  nature  should  be 
undertaken  until  the  child  is  two  months  old,  the  tumour  being 
merely  protected  and  supported  by  the  adjustment  of  pads  of  lint 
or  Gamgee  tissue. 

Simple  aspiration  of  the  sac  is  not  advisable,  as  sudden  death 
not  infrequently  results.  Ligature  and  excision  of  the  sac  should 
never  be  undertaken  since  they  are  both  dangerous  procedures,  and 
under  any  circumstances  can  only  be  practised  in  cases  of  simple 


Fig.  66. — Myelo-meningocele  in  the  lumbo- 
sacral region  of  a  young  child.  The  nerv-es 
of  the  Cauda  equina  form  a  flat  band 
attached  to  the  lower  part  of  the  sac  which 
is  puckered  ;  some  of  the  nerves  pass  to 
the  sac  wall  at  the  sides.  (Westminster 
Hospital  Museum,  No.  1279.  Drawn  by 
C.  H.  Freeman.) 


2  68  MANUAL   OF   SURGERY  chap. 

meningocele,  which  it  is  usually  impossible  to  distinguish  from 
meningo-myelocele. 

The  only  radical  treatment  to  be  recommended  is  by  the  injec- 
tion of  ^Morton's  fluid  (iodine,  grs.  lo  ;  iodide  of  potassium,  grs.  30  ; 
glycerine,  si.),  and  this  is  not  appHcable  to  all  cases.  If  the  sac- 
wall  is  unhealthy  and  very  thin,  if  the  general  health  is  bad,  and  if 
convulsions,  paralysis,  or  marked  hydrocephalus  is  present,  treatment 
by  Morton's  fluid  is  dangerous.  The  most  favourable  cases  are 
those  in  which  the  sac  is  small  and  its  coverings  sound,  the  general 
health  good,  and  the  condition  unaccompanied  by.  complications. 
In  properly  selected  cases  the  injection  of  Morton's  fluid  is  success- 
ful in  about  50  per  cent.      The  injection  is  made  as  follows : — 

A  fine  and  perfectly  clean  needle  is  passed  into  the  sac ;  it  is 
very  important  that  the  puncture  should  be  made  at  the  base 
through  healthy  skin.  If  the  sac  is  very  tense  a  little  of  the  fluid 
may  be  drawn  off,  but  otherwise  this  is  unnecessary.  From  half  to 
one  and  a  half  drachms  of  the  fluid  is  then  slowly  iniected,  the 
needle  is  withdrawn,  and  the  puncture  closed  with  collodion.  The 
tumour  should  then  be  covered  with  a  wool  dressing  carefully 
bandaged  on  to  afford  support.  The  fluid  diffuses  slowly,  and 
remains  limited  to  the  sac  if  the  patient  be  kept  quiet  in  the 
recumbent  position.  Following  the  injection  there  may  be  some 
slight  signs  of  inflammation,  but  these  soon  disappear,  and  in 
successful  cases  the  sac  gradually  contracts,  hardens  and  -is 
eventually  obliterated  by  new  fibrous  tissue,  as  the  result  of  chronic 
inflammation.  The  nerves  traversing  the  sac  are  incorporated  in 
this  new  tissue  but  are  not  usually  injuriously  compressed,  although 
such  an  unfortunate  result  may  occur  with  consequent  paralysis 
and  anesthesia.  The  injection  may  require  repeating,  but  this 
should  not  be  done  for  ten  days  or  a  fortnight  after  the  first  opera- 
tion. The  dangers  of  the  proceeding  are  shock,  sloughing  and 
rupture  of  the  sac,  convulsions  and  meningitis,  and  the  friends 
should  be  informed  of  these  possible  results  and  of  the  probable 
chances  of  success  before  the  operation  is  undertaken. 

In  cases  unsuitable  for  radical  treatment  protection  of  and  support 
to  the  tumour  is  all  that  can  be  done.  If  very  thin  the  sac  may  be 
advantageously  covered  with  a  thin  layer  of  gauze  and  collodion. 

SPINA    BIFIDA    OCCULTA 

Spina  bifida  occulta  is  the  name  given  to  a  rare  condition  in 
which  there  is  a  congenital  deficiency  of  the  neural  arches  in  the 


XII  SPINAL   CURVATURE  269 

lumbar  or  sacral  region,  but  without  any  hernial  projection  of  the 
contents  of  the  spinal  canal.  The  gap  is  filled  up  with  membrane 
and  is  indicated  by  a  slight  depression  on  the  surface,  or  at  least  by 
the  absence  of  the  normal  number  of  spinous  processes.  Growing 
in  and  round  the  depression  is  a  considerable  amount  of  hair, 
which  is  usually  dark  (the  skin  being  also  pigmented),  and  some- 
times many  inches  in  length.  Similar  growths  of  hair  have  been 
also  noted  in  the  cervical  region,  and  sometimes  the  trunk  is 
generally  more  hairy  than  natural.  In  conjunction  with  spina  bifida 
occulta  observers  have  recorded  the  occurrence  of  talipes,  per- 
forating ulcer,  and  caries  of  the  metatarsal  bones,  associated  with 
overgrowth  of  the  muscular  coats  of  the  arteries,  thrombosis  of  the 
veins,  and  degenerative  changes  in  the  nerves.  Virchow  considers 
that  the  growth  of  hair  at  the  seat  of  the  deformity  is  the  result  of 
local  irritation  due  to  disturbance  during  the  development  of  the 
spinal  column ;  and  it  may  be  assumed,  from  the  frequency  of  the 
association,  that  the  other  conditions  mentioned  have  a  central  origin. 

SPINAL    CURVATURE 

Causes. — Curvatures  of  the  spine,  unconnected  with  caries  of 
the  bones  forming  it,  may  occur  under  the  following  conditions  : — 

(i)  In  consequence  of  faulty  posture  during  the  years  of  active 
growth,  by  which  the  spine  is  habitually  placed  in,  and  encouraged 
to  assume,  an  abnormal  position.  This  is  especially  operative  in 
those  growing  rapidly  and  of  feeble  muscular  development. 

(2)  As  a  natural  consequence  of  old  age  and  the  following  of  any 
occupation  which  entails  continued  stooping  (agricultural  labourers), 
the  carrying  of  heavy  weights  upon  the  shoulders,  or  some  sedentary 
caUing  in  which  the  patient  bends  over  a  desk.  Such  causes  are 
especially  causative  of  kyphosis. 

(3)  As  compensation  for,  or  as  the  more  direct  result  of,  some 
pathological  condition  such  as  hip-disease  or  empyema. 

(4)  As  the  result  of  rickets. 

Varieties. — The  following  forms  of  curvature  are  met  \nth  : — 

Antero-posterior  curvatures. — (a)  lordosis,  in  which  the  con- 
vexity of  the  curve  is  forwards ;  {d)  kyphosis,  in  which  the  con- 
vexity of  the  curve  is  backwards. 

Lateral  curvature  or  scoliosis. 

The  angular  curvature  of  Pott's  disease,  and  that  which  may 
occur  in  cases  of  tumour  of  the  column  are  considered  under 
those  conditions. 


2  70  MANUAL   OF   SURGERY  chap. 

LORDOSIS 

In  lordosis  or  "  saddle-back  "  the  convexity  of  the  curve  looks 
forwards. 

Etiolog"y. — This  deformity  is  met  with  in  the  lumbar  region 
and  is,  like  kyphosis,  an  exaggeration  of  the  normal  curve. 

In  children  capable  of  walking  rickets  may  lead  to  an  increase 
of  the  lumbar  curve;  but  in  the  great  majority  of  cases  lordosis  is 
compensatory,  due  either  to  the  deformity  of  hip-disease,  of  con- 
genital or  unreduced  dislocation  of  the  femur,  or  of  rickety  or 
other  deformity  of  the  pelvis  or  lower  limbs. 

Angular  curvature  in  any  part  of  the  column  leads  to  the 
formation  of  secondary  lordotic  curves,  the  situation  of  which  will 
depend  upon  the  seat  of  the  angular  deformity. 

Temporary  slight  lordosis  may  be  due  to  increase  of  the 
abdominal  contents  {e.g:  pregnancy,  ascites),  necessitating  additional 
curvature  of  the  lumbar  spine  in  order  that  the  upright  position 
may  be  maintained — such  cases  do  not  come  under  the  care  of  the 
surgeon ;  transitory  lordosis  may  also  be  due  to  muscular  irritation 
of  reflex  origin. 

Anatomy. — In  recent  and  temporary  lordosis  no  permanent 
changes  are  met  with,  but  in  old  standing  cases  the  spines  of  the 
vertebrae  are  approximated,  the  discs  are  compressed  behind  but 
thickened  in  front,  and  the  muscles  and  ligaments  are  contracted 
and  shortened  on  the  concave  side,  but  are  relaxed  and  stretched 
on  the  convex.  In  rheumatic  patients  the  ligaments  may  be 
ossified,  and  osteophytes  may  be  present  on  the  bodies  and  pro- 
cesses of  the  vertebrae. 

In  cases  of  lordosis  the  patient  walks  very  erect  with  the 
shoulders  thrown  well  back  and  the  belly  protruded. 

Treatment. — Treatment  must  be  directed  to  an  avoidance  of 
those  causes  which  may,  if  neglected,  eventually  lead  to  the 
deformity  or  to  a  rectification  of  them  as  far  as  may  be  when 
lordosis  is  actually  present.  Rickety  children  must  be  kept  in  the 
recumbent  position  in  a  wicker  cradle,  until  by  general  treatment 
the  pathological  conditions  have  been  remedied  and  the  spine  is 
able  to  bear  the  necessary  weight. 

KYPHOSIS 

In  kyphosis  the  convexity  of  the  curvature  is  directed  back- 
wards.      It    is    usually  limited    to    the    dorsal    region    and    is    an 


XII 


KYPHOSIS 


27  I 


exaggeration  of  the  normal  posterior  curvature  in  this  situation,  but 
it  may  affect  the  whole  column. 

Causes. — The  normal  curvatures  of  the  spinal  column  are  but 
slightly  marked  until  a  child  begins  to  assume 
the  upright  position.  Before  this  time 
kyphosis  may  be  induced  if  the  child  is 
nursed  in  the  upright  position,  since  the 
column  is  not  strong  enough  to  support 
the  weight  of  the  trunk.  Rickets  tends  to 
cause  kyphosis,  because  the  column  is  un- 
stable and  there  is  muscular  and  general 
weakness.  Prolonged  stooping  positions, 
especially  if  combined  with  insufficient 
bodily  exercise  may  (especially  in  girls  at 
the  age  of  puberty  when  they  are  rapidly 
developing)  cause  bending  of  the  column ; 
but  in  such  cases  scoliosis  is  much  more 
common  than  kyphosis.  In  advanced  life 
most  people  show  some  degree  of  kyphosis. 

The  subjects  of  chronic  bronchitis  often 
become  very  round-shouldered,  and  rheu- 
matoid arthritis  may  lead  to  a  like  result. 

Anatomy. — In  early  cases,  which  are 
capable  of  complete  cure  by  appropriate 
means,  no  changes  are  met  with,  but  in 
permanent  and  old  standing  cases  there  will 
be  separation  of  the  bones  and  lengthening 
with  relaxation  of  the  ligaments  on  the  convex  and  the  reverse 
conditions  on  the  concave  side  of  the  bend.  The  separation 
of  the  bodies  behind  and  approximation  in  front  is  compen- 
sated for  by  growth  or  atrophy  of  the  intervening  discs ;  but  if 
the  kyphosis  is  present  during  the  stage  of  growth  of  the  spine, 
the  bodies  themselves  become  wedge-shaped,  the  apex  of  the 
wedge  being  anterior.  Changes  such  as  these  necessarily  render 
the  condition  permanent.  In  the  subjects  of  rheumatism  or 
rheumatoid  arthritis  the  ligaments  may  be  ossified.  In  conse- 
quence of  the  changes  in  the  spine,  the  thorax  is  increased 
in  its  antero-posterior,  and  diminished  in  its  lateral  diameters ; 
the  sternum  may  be  slightly  bent  with  the  convexity  backwards. 
The  head  is  depressed,  the  chin  approaches  the  sternum,  and 
the  shoulders  are  much  rounded  and  raised,  so  that  the  lower 
angles  of  the  scapulae  project.     In  marked  cases  of  kyphosis  the 


Fig.  67.  —  Kyphosis  aflfecting 
the  entire  spinal  column 
(Follin). 


272 


MANUAL  OF  SURGERY 


CHAP. 


patient    looks    upon    the    ground,    being    unable    to   look  straight 
forwards. 

Treatment. — In  cases  occurring  in  young  subjects  the  treat- 
ment is  practically  that  described  under  scoliosis ;  the  kyphosis  of 
old  age  requires  none.  Weak  or  rickety  children  should  rest  in 
the  recumbent  position,  and  the  muscular  tone  and  development 
should  be  encouraged  by  shampooing,  douching,  friction,  and,  if 
the  child  be  old  enough  and  when  the  muscular  power  has  been 
increased  by  these  means,  by  mild  gymnastics. 


SCOLIOSIS 

Etiology. — Scoliosis  or  lateral  curvature  of  the  spine  usually 
occurs  in  rapidly  growing  girls  about  the  age  of  puberty,  and  is, 
in  some  cases,  traceable  to  an  inherited  tendency.  The  rapid 
growth  at  this  age  is  often  out  of  proportion  to  the  strength  of  the 
muscles  and  supporting  structures  of  the  column,  and  the  curvature 
is  further  favoured  by  ansemia  and  the  more  sedentary  habits  of 
the  patient  with  the  onset  of  the  menses  and 
sexual  development.  Slouching  and  incorrect 
attitudes,  especially  if  maintained  for  long 
periods  during  piano-playing,  drawing,  or  read- 
ing, are  factors  of  importance  in  the  production 
of  the  deformity,  since  the  base  of  support  of 
the  column  (the  pelvis)  is  movable,  and  if  it  is 
tilted  to  one  side  there  is  a  compensatory 
curvature  of  the  column  which  may  become 
permanent. 

Rickets  may  induce  scoliosis  unless  great 
care  be  taken  to  take  weight  off  the  column. 

Empyema  may,  if  the  chest  fall  in,  be  com- 
pensated for  by  lateral  curvature. 

Inequality  in  length  of  the  lower  limbs  is 
an  important  cause,  and  its  early  rectification 
will  arrest  the  deformity  ;  the  same  applies  to 
errors  of  refraction,  especially  w^hen  the  focus 
of  the  two  eyes  differs. 

Anatomy  and  clinical    characters. — 

Scoliosis  is  a  spiral  twist  of  the  vertebral  column, 

the  vertebrae  rotating  round  a  vertical  axis.    The 

degree  of  associated  lateral  deviation  varies. 

The  rotation  of  the  vertebrae  is  greatest  at  the  centre  of  the 


Fig.  68. — Scoliosis 
(Follin). 


XII 


SCOLIOSIS 


273 


curve,  and  here  may  amount  to  as  much  as  a  quarter  of  a  circle, 
gradually  becoming  less  above  and  below.  The  rotation  takes 
place  towr.:-ds  the  convexity  of  the  curve,  the  spines  of  the  verte- 
brce  turning  to  the  concavity,  so  that  the  line  of  these  does  not 
indicate  the  degree  of  curvature. 

The  initial  curve  is  in  the  lumbar  region  with  the  convexity  to 
the  left,  the  compensatory  dorsal  curvature 
being  to  the  right ;  in  some  cases  the  curva- 
tures are  in  the  opposite  direction.  As  the 
muscles  are  unable  to  support  the  column  in 
the  straight  position,  considerable  strain  is 
thrown  upon  the  ligaments,  which  become 
stretched  on  the  convex  side  and  shortened 
on  the  concave.  The  bodies  of  the  vertebrae 
and  the  discs  on  the  concave  side  tend  to 
atrophy  from  pressure,  whereas  on  the  convex 
side  they  grow  more  rapidly ;  and  hence 
become  wedge-shaped  with  the  base  at  the 
convex  side ;  the  result  of  this  will  be  to  render 
the  curvature  permanent.  The  actual  nature 
and  extent  of  these  anatomical  changes 
naturally  depend  upon  the  degree  and  dura- 
tion of  the  scoliosis,  and  upon  the  means 
taken  to  remedy  the  defect ;  they  may  be  so 
slight  as  to  leave  no  permanent  changes. 

The    altered    direction    of    the    vertebrae 
necessarily  causes  a  corresponding  alteration  in  the  shape  of  the 
chest  and  in  the  patient's  configuration. 

The  child  is  probably  brought  to  the  surgeon  because  her 
shoulder  or  hip  is  "growing  out,"  the  former  on  the  convex  side, 
and  the  latter  on  the  concave  side  of  the  dorsal  curve  (Fig.  69). 

The  right  shoulder  is  raised  and  the  scapula  rendered 
prominent,  since  the  ribs  are  carried  backwards.  The  right  ribs 
are  bent  at  their  angles  and  the  intercostal  spaces  are  widened, 
while  on  the  left  the  angles  are  opened  out.  Viewed  from  the 
front,  the  chest  will  be  found  to  be  flattened  on  the  convex  side, 
but  bulged  and  the  breast  prominent  on  the  concave  side 
(Fig.  70,  p.  274). 

On  the  convex  side  the  clavicle  is  considerably  curved ;  the 
sternum  is  oblique  and  its  lower  end  is  prominent ;  the  pelvis  is 
not  usually  altered  unless  the  patient  has  been  the  subject  of  rickets. 

In   the   early  stages  of  the  deformity  the  spine  can  be  com 

VOL.  I  T 


Fig.  69. — Scoliosis 
(Till  mans). 


2  74  MANUAL   OF  SURGERY  chap. 

pletely  straightened  out  by  extension,  but  later  on,  when  the  before- 
mentioned  changes  have  occurred  in  the  bones,  discs,  and  liga- 
ments, no  complete  rectification  of  the  deformity  can  occur. 
Scoliotic  patients  are  usually  pale,  feeble,  and  easily  tired ;  they 
are  liable  to  bronchial  affections,  which  may  prove  serious,  owning 
to  the  undeveloped  state  of  the  chest. 

Prognosis. — The  prognosis  in  scoliosis  depends  upon  the 
circumstances  of  each  individual  case.  If  the  condition  is  marked, 
and  there  is  evident  axial  and  lateral  deviation,  this  will  remain 
permanently ;  but,  speaking  generally,  it  may  be  said  that  if  ex- 
amination shows  that  the  spine  can  be  straightened  by  extension, 


Fig.  70. — Illustrating  the  alteration  in  shape  of  the  ribs,  and  the  deviation  of  the 
transverse  diameter  of  the  thorax  in  scoliosis  (Tubbj',  after  Redard) 

the  prognosis  is  good  and  the  patient  may  grow  up  without  any 
very  evident  deformity.  The  later  the  age  at  which  the  scoliosis 
appears  the  better.  If  the  curvature  is  dependent  on  inequality  of 
the  lower  limbs,  it  will  soon  disappear  if  this  be  rectified  by  a  high- 
soled  boot  for  the  shorter  limb. 

Treatment. — As  the  great  majority  of  cases  of  scoliosis  are 
dependent  upon  weakness  of  the  supporting  structures  of  the  spine, 
improvement  in  the  nutrition  and  strength  of  these  is  of  the  first  im- 
portance. The  application  of  spinal  supports  is  likely  to  do  more  harm 
than  good,  since  it  aims  at  straightening  the  column  by  mechanical 
means  instead  of  inducing  the  muscles  and  ligaments  to  efficiently 
perform  their  work.  Artificial  support  may,  however,  be  occasionally 
employed  with  advantage  if  the  patient  complains  of  much  pain,  or 


XII        DEFORMITIES   OF  THE   HEAD   AND   NECK      27 


n 


if,  in  spite  of  other  treatment,  the  deformity  is  rapidly  increasing;  a 
proplastic  jacket  is  to  be  preferred,  since  it  can  be  readily  removed. 

Faulty  habits  and  slouching  attitudes  must  be  at  once  corrected. 
Moderate  gymnastics,  friction,  and  massage  to  the  spinal  muscles, 
especially  those  on  the  convex  side  of  the  curve,  with  cold  douch- 
ing, must  be  daily  employed,  and  the  patient  should  take  outdoor 
exercise  but  never  to  fatigue.  If  the  curvature  is  advancing  and 
the  patient  is  weak,  anaemic,  and  growing  rapidly,  it  will  be  necessary 
for  her  to  assume  the  recumbent  position  for  some  hours  daily,  and 
the  gymnastic  exercises  must  be  limited  in  amount  to  her  powers. 

In  all  cases  the  general  health  must  be  encouraged  by  fresh  air, 
good  food,  and  tonics. 

Deformities  of  the  Head  and  Neck 


CRANIA    BIFIDA 

Owing  to  a  deficiency  in  the  cranium  its  contents  may  protrude 
through  the  opening,  and  give  rise  to  a 
definite  tumour.  If  only  the  meninges 
project  the  sac  is  filled  with  cerebro-spinal 
fluid,  and  may  be  quite  translucent  (memn- 
gocele) ;  but  in  many  cases  more  or  less 
cerebral  substance  is  present  {encephaloc€k\ 
making  the  tumour  more  dense  and  solid 
than  in  the  case  of  simple  meningocele ; 
it  will  pulsate  with  respiration.  The  skin 
over  such  a  tumour  may  be  quite  normal, 
but  it  is  sometimes  naevoid ;  it  often 
ulcerates,  and  eventually  yields,  so  that 
the  child  dies  of  meningitis. 

Crania  bifida  is  usually  met  with  in 
the  occipital  region  midway  between  the 
foramen  magnum  and  the  posterior 
fontanelle   in    the    middle    line ;    it   also 

occurs  at  the  root  of  the  nose  (Fig.  70A),  at  either  fontanelle,  or 
through  the  base  of  the  skull  into  the  nose  or  pharynx. 

Spina  bifida,  hydrocephalus,  and  other  deformities  may  be 
associated. 

Diagnosis. — The  congenital  origin  of  the  tumour  and  its  posi- 
tion will  lead  the  surgeon  to  suspect  its  nature.  The  fluid  may  be 
partly  displaced  into  the  cranial  cavity  by  steady  pressure,  and  a  small 
meningocele  may  be  almost  completely  reducible.     If  brain  matter  is 


Fig.  70A. — Meningocele  at  the  root 
of  the  nose  (Brj-ant,  from  a 
patient  of  Mr.  Poland). 


2  76  MANUAL  OF  SURGERY  chap. 

present,  it  may  be  in  sufficient  quantity  to  render  the  tumour  solid,  and 
make  respiratory  pulsation  very  evident,  but  in  some  cases  the  brain 
matter  is  very  small  in  amount,  and  cannot  be  certainly  detected. 

A  small  meningocele  is  by  no  means  incom.patible  with  life, 
although  it  infinitely  rarely  undergoes  spontaneous  cure.  En- 
cephaloceles  tend  to  steadily  increase  in  size.  Most  children  with 
crania  bifida  die  within  a  few  weeks  of  birth. 

Treatment. — This  consists  in  supporting  the  tumour  and  pre- 
venting it  from  being  injured.  If  the  case  is  undoubtedly  one  of 
simple  meningocele,  and  the  child  is  otherwise  healthy,  the  sac  may 
be  excised,  the  base  of  it  being  very  carefully  sutured  across  the  open- 
ing ;  the  presence  of  any  brain  matter  negatives  such  an  operation. 

Injection  with  Morton's  fluid  should  not  be  undertaken- 

TORTICOLLIS    OR    WRYNECK 

Torticollis  is  false  or  true,  and  the  latter  may  be  spasmodic  or 
permanent. 

^  False  torticollis  is  the  condition  in  which  the  head  is  volun- 
tarily bent  to  one  side  in  consequence  of  some  local  disease.  It  is 
seen  in  cases  of  spinal  caries,  enlarged  glands,  cellulitis,  and  abscess 
about  the  neck,  or  as  simple  stiff  neck  from  rheumatism  or  cold.  In 
these  cases  the  muscles  are  contracted  on  the  side  of  the  disease  lead- 
ing to  the  wryneck,  and  if  such  disease  be  removed  the  contraction  is 
at  once  relaxed.     The  treatment  must  have  reference  to  the  cause. 

True  torticollis. — Spasmodic  tortieollis  is  usually  uni^ 
lateral,  and  may  affect  the  sterno-mastoid  muscle  only,  or  also 
the  posterior  deep  cervical  muscles,  in  which  case  the  head  is 
drawn  backwards  and  laterally  {RetrocoUis).  The  spasm  may  be 
cIo?iic  or  tonic,  and  often  intermits,  so  that  the  patient  may  be  free 
from  it  for  weeks  together,  or,  although  persistent,  it  may  be  very 
much  worse  sometimes  than  at  others,  and  often  is  so  if  the  patient's 
attention  is  drawn  to  it.  Unless  the  case  is  very  bad  there  is  no 
spasm  during  sleep.  The  spasm  does  not  cause  fatigue  of  the 
muscles,  although  cramp  and  pain  are  experienced  after  a  time. 
The  muscles  do  not  undergo  any  pathological  change. 

Spasmodic  torticollis  is  usually  seen  in  young  women,  especially 
those  who  are  highly  neurotic  (hysterical) ;  it  is  sometimes  dependent 
upon  reflex  irritation,  such  as  decayed  teeth,  enlarged  glands,  and  the 
like,  and  such  a  cause  should  always  be  sought  for  and  removed.  Irri- 
tation may  also  directly  affect  the  spinal  accessory  nerve  or  its  roots. 

Treatment. — Anti-spasmodics,  combined  with  tonics,  should   be 


XII 


TORTICOLLIS   OR   WRYNECK 


277 


given  a  fair  trial  Conium,  morphia,  cannabis  indica,  and  the 
bromides  should  be  tried,  combined  with  the  use  of  galvanism.  If 
this  treatment  fails,  the  spinal  accessory  nerve  should  be  divided, 
and  if  after  this  the  posterior  muscles  give  trouble,  the  posterior 
cervical  nerves  may  be  similarly  dealt  with. 

Permanent  torticollis. — Contraction  of  one  sterno-mastoid 
maintaining  the  head  in  a  fixed  position  may  be  due  to  injury  of 
the  muscle  at  birth,  which  causes  a  haematoma  and  subsequent  con- 
traction of  the  muscle  {ster7W-7nastoid  tumour^  see  p.  140,  vol.  ii.),  but 
this  association  is  by  no  means  constant,  and  although  the  associa- 
tion as  cause  and  effect  is  maintained  by  some  writers,  it  is  denied 
by  others.  Syphilitic  myositis  and  pronounced  astigmatism  are  also 
causative  agents.      In  some  cases  no  cause  can  be  assigned. 

The  sterno-mastoid  is  the  muscle  primarily  at  fault,  and  may 
be  the  only  one  affected,  but  in  some 
cases  the  deep  muscles  are  also  im- 
plicated. The  cervical  fascia  is  often 
contracted.  The  muscle  is  dense, 
hard,  and  stands  out  prominently,  the 
two  heads  of  origin  being  well  defined. 
The  occiput  is  drawn  to  the  same, 
and  the  face  to  the  opposite  side ; 
the  chin  and  shoulder  are  raised,  and 
the  clavicular  curves  are  specially 
pronounced. 

This  continued  contraction  of  the 
muscles  of  one  side  of  the  neck  may 
produce  a  lateral  deviation  of  the 
cervical  spine,  with  a  compensatory 


dorsal  curve.      In  marked  congenital 


Fig.  71. — Congenital  torticollis,  showing 
asymmetry  of  the  face  in  a  child  three 
years  ten  months  old  (Tubby), 


cases  the  face  on  the  affected  side  may  not  be  fully  developed,  as 
can  be  shown  by  careful  measurement  (Fig.  71). 

Treatment. — Any  contributory  cause,  such  as  syphilis  or  astig- 
matism, must  be  corrected,  and  this,  coupled  with  daily  manipula- 
tion and  massage,  and  the  use  of  a  leather  collar  or  support,  may 
correct  the  deformity  in  early  cases. 

If  tenotomy  is  needful,  this  should  be  performed  by  the  open 
method,  since  the  subcutaneous  is,  in  view  of  the  important  relations 
of  the  sterno-mastoid,  too  dangerous  a  procedure.  An  incision  is 
made  about  1%  inch  above  the  clavicle,  and  the  tendons  of  the 
sterno-mastoid  are  fully  exposed,  and  divided  by  short  snips  with 
the  scissors.     Care  must  be  taken  that  the  anterior  and  external 


278  MANUAL   OF   SURGERY  chap. 

jugular  veins  and  the  vessels  beneath  the  muscle  are  not  damaged. 
The  wound  should  be  closed,  and  the  head  may  be  at  once  immo- 
bilised in  the  correct  position  on  a  suitable  apparatus.  In  old  cases, 
where  the  cervical  fascia  is  contracted,  this  may  be  carefully  divided, 
but  if  the  contraction  is  but  slight,  it  will  usually  be  overcome  in 
time  without  operation.  The  apparatus  should  be  worn  continu- 
ously for  about  three  weeks,  and  during  the  day  for  another  week. 
At  the  end  of  a  fortnight  gentle  massage  should  be  employed  to  the 
side  of  the  neck. 

Complete  cure  of  the  deformity  can  hardly  be  looked  for  if  a 
lateral  curvature  of  the  cervical  spine  has  been  induced. 

Congenital  Malformations  of  the  Mouth,   Lips,   and  Face 

Normal  development. — The  face  is  developed  by  the  partial 
union  of  a  vertical  plate  known  as  the  fronto-nasal  process,  with  two 
superior  and  two  inferior  lateral  plates — the  maxillary  and  mandi- 
bular. The  fronto-nasal  process  grows  downwards  from  the  base  of 
the  skull  between  the  ocular  vesicles,  and  at  its  lower  end  is  deeply 
notched  on  each  side  to  form  the  nostril ;  the  lateral  margins  of 
the  notches  form  the  alse  nasi  while  the  central  portion  which 
separates  the  two  nostrils  gives  rise  to  the  tip  of  the  nose,  the 
columella,  the  central  grooved  portion  of  the  upper  lip,  and  the 
intermaxillary  bone  with  the  incisor  teeth. 

The  maxillary  plates  grow  forwards  towards  the  middle,  where 
they  unite  with  the  fronto-nasal  process  on  each  side,  and  thus  fcrm 
the  upper  lip  and  cheek  above  the  level  of  the  angle  of  the  mouth. 
The  mandibular  and  maxillary  plates  unite  posteriorly  to  the  angle 
of  the  mouth ;  in  front  of  this  point  the  former  give  rise  to  the 
lower  lip.  Imperfect  union  of  any  of  these  processes  will  result  in 
hare-lip,  cleft  lower  lip,  macrostoma,  or  cleft  cheek,  according  to  the 
position  at  which  such  imperfection  occurs. 

The  palate  is  formed  by  the  union  of  the  intermaxillary  bone 
with  the  maxillary  plates,  and  behind  by  that  of  the  palatine  pro- 
cesses of  the  maxillary  plates,  to  which  is  joined  above  the  fronto- 
nasal process  forming  the  septum  nasi.  The  union  of  the  com- 
ponent structures  of  the  palate  and  upper  lip  takes  place  from 
before  backwards. 

HARE-LIP 

Hare-lip  is  due  to  failure  of  union  of  the  lower  end  of  the  fronto- 
nasal process  with  that  portion  of  the  m.axillar)'  plate  which   forms 


XII 


HARE-LIP 


279 


the  lateral  part  of  the  upper  lip.  The  deformity  may  be  single  or 
double ;  the  cleft  may  be  partial,  or  extend  right  into  the  nostril, 
and  may  or  may  not  be  associated  with  cleft  palate.  Hare-lip  is 
more  common  in  boys  than  girls  and  is  not  infrequently  hereditary. 
The  term  hare-lip  is  incorrect,  as  the  cleft  in  the  hare's  lip  is 
central. 

Single  hare-lip  occurs  more  usually  on  the  left  side.  The 
general  appearances  of  the  single  and  double  deformities  are  well 
shown  in  the  figures.  If  the  cleft  be  single,  and  especially  if  it  be 
slight,  there  is  practically  no  difficulty  in  feeding  the  child,  but  in 
the  more  severe  cases  and  those  associated  with  cleft  oalate  such 


Fig.    72.— Single  hare-lip  on      Fig.   73. — Single  hare-lip  on       Fig.  74.— Double  hare-lip  with 
the  right  side  with  a  cleft  the    left    side    extending  complete  cleft  palate.     The 

into      the      nostril      and  intermaxillary  bone  covered 

through       the       alveolar  with  skin  is  attached  to  the 

border.    (Follin.)  tip  of  the  nose.     The  alae 

nasi  are  broadened  and  the 
nose  flattened.  (Drawn  by 
C  H.  Freeman.) 


of  the  alveolar  margin. 
The  intermaxillary  bone 
forms  a  marked  promin- 
ence to  the  left  of  the 
cleft.    (Follin.) 


difficulty  is  great,  and  unless  care  be  taken  the  child  will  suffer 
severely  from  malnutrition.  The  method  of  feeding  is  the  same  as 
in  cases  of  cleft  palate  (see  p.  282). 

Operation  for  single  hare-lip. — Clefts  of  the  lip  should  be 
operated  on  when  the  child  is  about  a  month  or  six  weeks  old,  and 
should  always  be  closed  before  the  seventh  month,  i.e.  before 
primary  dentition  begins.  The  operation  may,  if  the  parents  so 
desire,  be  safely  performed  within  a  few  days  of  birth,  but  the  risk 
of  failure  is  greater  and  slight  cases  only  should  be  undertaken  at 
this  age.  The  operation  consists  in  paring  and  uniting  the  edges 
of  the  cleft  with  silkworm  gut  and  horsehair.  The  precise  operation 
and  lines  of  incision  must  vary  with  the  circumstances  of  the  case. 
The  accompanying  figures  (Figs.  75  to  79,  p.  280)  show  the 
methods  which  are  most  usually  applicable.     In  all  cases  the  lip 


28o 


MANUAL  OF  SURGERY 


CHAP. 


must  be  freely  detached  from  the  subjacent  bone  by  snipping  through 
the  mucous  membrane  and  soft  structures,  so  that  there  may  be  no 
undue  tension  on  the  sutures.   Haemorrhage  is  prevented  by  grasping 


Fig.  75- — Rose's  operation  for  single 
hare-lip.  The  dark  lines  indicate 
the  lines  of  incision. 


Fig.  76. — Pose's  operation  completed 
by  suturing  of  the  freshened  sur- 
faces. 


the  lip  between  the  finger  and  thumb,  and  when  the  edges  of  the 
cleft  have  been  pared,  the  sutures,  which  are  passed  almost  through 
the  thickness  of  the  lip  but  not  through  the  mucous  membrane,  will 
effectually  control  the  vessels,  so  that  no  Hgatures  are  either  necessary 
or  advisable.  Accurate  suturing  is  essential,  so  that  the  normal 
contour  of  the  lip  should  be  attained.  When  the  cleft  has  been 
united  the  lip  should  be  everted  and  the  mucous  membrane  drawn 


Fig.  77. — Mirauk's  operation 
for  single  hare-lip.  The 
dark  line  indicates  the  line 
of  incision. 


Fig.  78. — Mirault's  opera- 
tion, showing  the 
freshened  surfaces. 


Fig.  79. — Mirault's  opera- 
tion concluded  by- 
suturing  of  the  fresh- 
ened surfaces. 


together  by  a  few  horse-hair  sutures.  When  the  operation  is  com- 
pleted the  parts  are  covered  with  a  thin  layer  of  salicylic  wool  and 
collodion,  which  may  remain  untouched  for  four  or  five  days ;  the 
sutures  should  be  removed  at  the  end  of  a  week.  If  the  gap  is 
wide  and  there  is  the  least  tension  on  the  sutures,  the  centre  of  a 
narrow  bandage  is  placed  on  the  forehead,  and  the  ends  are  carried 
beneath  the  occiput  and  then  brought  forwards  over  the  lip,  one 
end  is  split,  and  the  two   pieces  are   drawn   through   slits  in  the 


XII 


HARE-LIP 


281 


opposite  end ;  by  drawing  on  the  two  ends  the  edges  of  the  cleft  are 
brought  together,  and  the  bandage  is  then  knotted  behind  the 
occiput. 

For  the  success  of  the  operation  it  is  essential  that  the  child 
should  be  in  good  health. 

Operation  for  double  hare-lip. — In  cases  of  double  hare- 
lip the  premaxillary  bone  covered  by  the  skin, 
which  should  form  the  columella  of  the  nose 
and  the  central  portion  of  the  upper  lip,  is 
attached  to  the  end  of  the  nose  and  helps  to 
fill  up  the  gap  (Fig.  80).  The  first  question  to 
be  decided  is  whether  the  premaxillary  bone 
should  be  left  i7i  siiii  or  should  be  removed ;  the 
answer  to  this  must  depend  upon  circumstances  ; 
if  the  premaxilla  is  projecting  prominently  for- 
ward it  should  be  removed,  but  in  other  cases 
it  may  advantasjeously  be  left,   as  its  presence   ^'^-  So.— Profile  view  of 

■'  .  a.  case  of  double  hare- 

serves  as  a  support  to  the  lip  and  will  not  in- 
terfere with  union.  The  plan  of  forcibly  bend- 
ing the  premaxilla  back  into  position  is  recom- 
mended by  some  surgeons,  but  it  has  the  dis- 
advantage, inter  a/ia,  of  pushing  the  dental 
border  into  an  abnormal  position  so  that  the  teeth  when  cut  project 
backwards. 

If  it  is  decided  to  remove  the  premaxillary  bone  the  skin  and 


lip.  The  intermaxillary 
bone  and  central  incisor 
teeth  are  attached  to 
the  tip  of  the  nose  with 
which  the  skin  covering 
is  continuous.  (Fergus- 
son.) 


Fig.  81. — Anterior  view  of  the  premaxillary 
bone  from  a  case  of  double  hare-lip. 
The  gum  has  been  divided  on  each  side 
to  show  the  incisor  teeth,  a,  a.  (West- 
minster Hospital  Museum,  No.  392.) 


Fig.  82. — Posterior  view 
of  Fig.  8i. 


soft  Structures  on  it  should  be  dissected  off  and  carefully  preserved 
and  the  bone  is  then  cut  away  with  forceps,  the  gap  being  at  once 
closed  or  the  operation  being  completed  in  two  or  three  weeks. 
The  union  of  the  lip  is  effected  in  much  the  same  way  as  for  single 
clefts,  the  skin  on  the  premaxillary  bone  being  used  to  form  the 
columella  as  shown  in  Figs.  83,  84,  p.  282. 

After-treatment — As    respiratory  difficulty  is   sometimes   ex- 


2^2  MANUAL   OF   SURGERY  chap. 

perienced  after  the  operation,  the  nurse  should  not  leave  the  child 
for  three  or  four  hours,  and  should  be  directed  to  draw  down  the 
lower  lip  and  jaw  if  such  an  event  should  occur.      In  cases  of  single 


Fig.  83. — Rose's  operation  for  double  Fig.  84. — Rose's  operation  completed 

hare-lip.     The  dark  lines  indicate  by  suturing  of  the  freshened  sur- 

the  lines  of  incision.  faces. 

hare-lip  the  child  may  take  the  breast  or  bottle,  but  in  double  hare- 
lip it  should  be  fed  by  means  of  a  tube  for  the  first  four  or  five 
days. 

Cleft  of  the  lower  lip  is  very  rare.  It  is  always  seen  in  the 
middle  line,  and  is  due  to  failure  of  union  of  the  mandibular  plates. 
The  edges  of  the  cleft  should  be  pared  and  united. 

Cleft  cheek  is  dependent  upon  imperfect  union  of  the  maxillary 
and  mandibular  plates.  The  defect  is  very  rare,  and  is  remedied 
by  paring  and  suturing  the  edges. 


CLEFT  PALATE 

If  the  palatine  portions  of  the  maxillary  plates  fail  to  unite,  cleft 
palate  results.  The  cleft  may  only  affect  the  uvula,  or  may  extend 
through  the  soft  and  hard  palates,  along  the  line  of  the  inter- 
maxillary suture  on  one  or  both  sides  and  through  the  alveolar 
border,  in  which  case  there  is  associated  single  or  double  hare-lip. 
AVhen  the  cleft  extends  through  the  hard  palate  the  septum  nasi  is 
imperfectly  developed  and  may  be  free,  but  is  usually  attached  to 
one  side  of  the  cleft,  more  frequently  to  the  right  than  to  the  left. 
As  the  child  grows  the  dental  arch  becomes  narrowed,  and  hence 
the  gap  is  contracted,  but  is  never  completely  obliterated. 

Cleft  palate  interferes  with  sucking,  and  hence  these  children 
require  very  careful  feeding,  or  they  fall  into  a  marasmic  condition. 
Bronchitis  and  broncho-pneumonia  are  dangers  to  be  guarded 
against.  In  later  life  the  tendency  to  regurgitation  of  fluids  through 
the  nose  and  the  characteristic  defect  of  speech  are  well  known. 

Treatment. — Children  with  cleft  palate  must  be  fed  by  means 
of  a  large  teat  with  a  flange  of  rubber  on  one  side,  which  will  fill  up 


XII 


CLEFT  PALATE 


283 


the  gap  and  allow  a  vacuum  to  be  formed  during  sucking.  If  this 
plan  does  not  answer,  the  child  must  be  fed  by  a  spoon  or  through 
a  tube  passed  well  back  to  the  pharynx  while  the  head  is  thrown 
back.  It  must  be  carefully  protected  from  cold.  The  treatment 
is  essentially  operative,  but  in  very  wide  clefts  of  the  hard  palate 
operation  does  not  offer  any  hope  of  closure,  and  in  such  cases  a 
properly  constructed  obturator  is  the  only  means  of  treatment. 
When  both  hard  and  soft  palates  are  cleft  they  should  be  united 
at  the  same  operation. 

Ag-e  for  operation. — If  the  cleft  does  not  involve  the  hard  palate 
it  may  be  united  any  time  after  the  first  year  and  should  be  closed 
before  the  child  learns  to  speak,  so  that  faulty  intonation  may  be 
reduced  to  a  minimum.  Clefts  of  the  hard  palate  may  be  subjected 
to  operation  after  the  fourth  year ;  but  if  the  cleft  is  very  broad,  it 
is  better  to  wait  until  about  the  age  of  six  or  seven,  for  the  tissues 
are  then  stouter  and  more  likely  to  unite,  the  child  is  intelligent 
enough  to  help  in  the  after-treatment,  and  the  cleft  has  somewhat 
narrowed,  owing  to  the  contraction  of  the  dental  arch.  No 
operation  is  admissible  unless  the  child  be  in  perfect  health  and 
free  from  all  throat,  or  ear  troubles. 

In  cases  of  operation  for  cleft  palate,  it  is  important  to  defer 
the  operation  until  the  child  has  been  properly  trained  to  refrain 
from  talking,  to  take  food  through  a  tube,  and  to  keep  the  mouth 
closed,  as  he  will  have  to  do  after  the  operation ;  such  a  plan  is  of 
great  importance  as  regards  success. 

Closure  of  the  soft  palate — Staphyloraphy. — The  patient 


Fig.  85. — Cleft  of  fhe  hard  and  soft  palates. 
The  line  on  each  side  parallel  with  the 
teeth  indicates  that  of  the  incision  through 
which  the  muco-periosteal  flap  is  raised. 


/rw7\ 


Fig.  86. — Closure  of  the  hard  and  soft 
palates.  The  line  seen  on  each  side 
in  Fig.  85  is  now  a  gap  which  heals 
by  granulation. 


is  placed  under  chloroform  and  the  mouth  is  well  opened  by  Smith's 
gag ;  the  neck  should  be  over-extended.     The  uvula  being  held  by 


284  MANUAL  OF  SURGERY  chap. 

a  mouse-tooth  forceps,  that  side  of  the  palate  is  put  on  the  stretch 
and  a  narrow  strip  is  removed  from  behind  forwards  ;  the  other  side 
is  similarly  freshened.  Fine  silkworm  gut  and  horse-hair  sutures 
are  introduced  from  before  backwards  about  J  inch  apart,  and  when 
all  have  been  passed  they  are  tied.  Silver-wire  is  not  necessary 
and  is  now  little  used.  It  is  important  that  the  sutures  should 
merely  hold  the  sides  of  the  palate  together  and  should  not  drag 
them  into  apposition,  for  if  there  be  any  tension  union  \nll  almost 
certainly  fail.  If  on  attempting  to  approximate  the  folds  it  is  found 
there  is  tension,  this  must  be  overcome  by  making  a  cut  on  each 
side  parallel  with  the  cleft  but  not  extending  to  the  free  border  of 
the  palate ;  if  there  is  still  tension,  the  tendinous  attachments  to  the 
hamular  process  on  each  side  must  be  separated  with  a  raspatory 
passed  through  the  lateral  incisions ;  tension  may  also  be  overcome 
by  dividing  the  pillars  of  the  fauces. 

Closure  of  the  hard  palate — Uranoplasty. — The  margins 
of  the  cleft  are  first  freshened,  and  then  an  incision  is  made  on  each 
side  near  the  alveolar  margin  extending  from  before  backwards 
from  the  anterior  end  of  the  cleft  to  the  junction  of  the  soft  and 
hard  palates  and  extending  down  to  the  bone  (Fig.  85,  p.  283).  All 
the  soft  structures  between  this  incision  and  the  margin  of  the  cleft 
are  then  separated  from  the  bone  by  a  curved  raspatory,  care  being 
taken  that  the  parts  are  not  bruised  or  unnecessarily  damaged. 
The  posterior  attachment  of  the  soft  palate  is  now  separated  from 
the  hard  by  scissors  which  are  introduced  through  the  lateral 
incisions.  By  this  means  a  loose  flap  is  detached  from  each  side, 
and  these  are  then  united  from  before  backwards  in  the  manner 
described  above. 

In  very  wide  clefts  a  broader  flap  may  be  secured  by  separating 
the  mucous  membrane  from  the  nasal  septum  as  well  as  from  the 
hard  palate :  the  septum  is  usually  attached  to  one  side  of  the  cleft 
and  the  incision  is  made  some  distance  up  it  instead  of  along  the 
margin  of  the  cleft. 

After-treatment. — The  food  must  be  of  a  fluid  nature,  and 
should  be  given  by  a  tube  for  the  first  week  or  ten  days ;  nothing 
solid  which  requires  mastication  should  be  allowed  for  at  least  a 
fortnight.  In  severe  cases  rectal  feeding  for  a  few  days  may  be 
advisable.  The  child  must  not  be  allowed  to  talk,  and  examina- 
tion of  the  mouth  should  be  deferred  until  about  the  tenth  day. 
It  is  advisable  to  gently  douche  the  mouth  with  Condy's  fluid  or 
dilute  "Listerine"  and  insufflate  a  little  iodoform  once  or  twice  daily. 

The  sutures  need  not  be  removed  for  three  weeks. 


XII  DEFORMITIES   OF  THE   LIMBS  285 

When  the  gap  is  closed  the  child  should  be  taught  to  talk  so 
that  its  faulty  intonation  which  is  partly  habit  may  be  improved, 
and  the  parents  should,  before  any  operation  is  undertaken,  be 
warned  that  it  will  not  by  any  means  completely  cure  the  defective 
speech ;  unless  they  are  warned  of  this  their  disappointment  will  be 
very  evident. 


Deformities  of  the  Limbs 
talipes  or  club-foot 

Causes. — Club-foot  may  be  congenital  or  acquired.  The  con- 
genital form  is  sometimes  hereditary,  and  is  often  bilateral  and 
associated  with  some  other  deformity,  e.^^.  spina  bifida ;  in  some 
cases  it  is  due  to  injury  at  the  time  of  birth. 

Congenital  cases  are  probably  due  in  most  cases  to  a  faulty 
position  m  iitero ;  in  some  to  nerve  lesions,  as  in  associated  spina 
bifida  ;  in  a  few  to  absence  or  incomplete  development  of  the  bones 
of  the  leg. 

Acquired  talipes  is  the  common  form  and  may  be  due  to  over- 
action  of  one  group  of  muscles,  while  the  opponents  act  normally;  or 
more  usually  to  the  normal  contraction  of  a  group  against  weakened 
or  paralysed  opponents ;  in  either  case  the  foot  is  dragged  in  that 
direction  towards  which  the  strongest  group  of  muscles  act.  The 
most  common  cause  of  such  disproportionate  strength  is  to  be 
found  in  infantile  paralysis,  but  it  may  also  be  occasioned  by 
hemiplegia,  lateral  sclerosis,  infantile  convulsions,  or  damage  to  any 
given  nerve  trunk.  Rupture  of  a  tendon  or  tendons,  cicatricial 
contraction  of  muscles  following  deep-seated  cellulitis  and  suppura- 
tion, or  the  contraction  after  a  severe  burn  may  also  induce  talipes. 
Disease  or  injury  of  an  epiphysis  by  arresting  growth  in  that  bone 
may  also  lead  to  the  deformity ;  thus  if  growth  be  arrested  at  the 
lower  end  of  the  tibia,  the  fibula  becomes  in  time  the  longer  bone, 
and  the  malleolus  pressing  against  the  calcaneum  may  force  the 
foot  into  the  position  of  T.  varus. 

Varieties. — The  following  varieties  of  tahpes  are  met  with,  but 
are  by  no  means  of  equally  common  occurrence. 

(i)  Talipes  equinus  (Fig.  90,  p.  288). — The  heel  is  drawn  up 
and  the  toes  are  pointed. 

(2)  Talipes  varus  (Fig.  91,  p.  289). — The  outer  border  of  the 
foot  rests  upon  the  ground,  the  sole  being  turned  inwards. 
These    two    forms    are  usually   combined,    giving   rise  to 


2  86  MANUAL  OF  SURGERY  chap. 

talipes  eqiiino-varus  (Figs.  92,  p.  290,  94,  p.  293),  which  is 
the  most  common  form  of  club-foot. 

(3)  Talipes  calcaneus  (Fig.  87,  p.  287)  is  the  reverse  of  equinus. 

(4)  Talipes  valgus  (Fig.  97,  p.  295)  consists  in  eversion  of  the 

foot  and  is  usually  associated  with  pes  planus. 

(5)  Talipes    calcaneo-valgus    is   a  combination  of  these   two 

varieties. 

(6)  Pes  planus  (Fig.  97,  p.  295). — The  arch  of  the  foot  is  much 

flattened,    and    there    is    associated    T.    valgus    or    genu 
valgum. 

(7)  Pes  eavus  (Figs.  95,  96,  p.  294). — The  arch  of  the  foot  is 

increased,  and  the  toes  may  be  depressed  from  associated 

T.  equinus  i^pes  arcuatus  2in^  plantaris). 
The  general  anatomy  of  talipes. — In  nearly  all  forms  of 
talipes  the  deformity  implicates  the  transverse  tarsal  arch,  but  in 
T.  equinus  and  calcaneus  the  ankle  joint  is  affected  in  consequence 
of  the  shortening  of  the  ligaments.  The  degree  of  wasting  of  the 
bones  and  muscles  is  proportionate  to  the  severity  of  the 
deformity  and  the  uselessness  of  the  foot.  In  most  cases  the 
bones  are  simply  atrophied  and  there  is  no  gross  change  in  their 
shape,  but  the  articular  surfaces  may  be  partly  obliterated  or 
broadened  in  conformity  with  the  displacement.  The  contracted 
muscles  are  shortened,  and  their  tendons  stand  out  prominently 
when  any  forcible  attempt  is  made  to  correct  the  deformity ;  the 
tendons  run  in  abnormal  directions.  The  weak  or  paralysed 
muscles  become  proportionately  elongated,  they  waste  and  under- 
go fatty  degeneration  and  atrophy.  The  ligamentous  structures 
share  in  the  shortening  and  contraction  or  elongation  and  atrophy 
in  the  same  way  as  do  the  muscles.  The  skin  and  subcutaneous 
structures  which  are  brought  in  contact  with  the  ground  are 
condensed  and  thickened  as  the  result  of  intermittent  pressure; 
corns  and  bursae  are  commonly  formed,  except  in  the  case  of 
young  children  who  do  not  put  the  feet  to  the  ground.  In 
paralytic  cases  the  Hmb  will  be  found  withered,  cold,  and  flabby,  and, 
if  the  deformhy  be  unilateral,  much  smaller  than  that  on  the  sound 
side. 

General  plan  of  treatment. — The  mere  correction  of  the 
deformity  is  by  no  means  the  only  object  to  be  aimed  at  in  treat- 
ment, for  it  is  essential  that  the  foot  must  not  only  look  shapely  but 
must  work  well  as  a  foot.  The  actual  treatment  must  be  prescribed 
with  a  full  knowledge  of  the  circumstances  of  the  case  and  with 
full    regard    to  the  degree   of  the  deformity  and   the  amount  of 


XII 


TALIPES   CALCANEUS 


287 


restitution  which  can  be  obtained  by  manipulation.  In  moderate 
cases,  especially  in  the  young,  daily  manipulation,  cold  douching, 
massage,  and  galvanism,  and  in  some  cases  the  employment  of  some 
form  of  shoe  or  mechanical  contrivance  may  effect  a  cure  and 
should  at  least  be  persevered  with  for  a  time. 

If  such  means  fail,  the  contracted  tendons  and  fascial  structures 
must  be  subcutaneously  divided,  after  which  the  foot  may  be  forcibly 
wrenched  into  the  correct  position.  In  bad  cases  more  severe 
operations,  such  as  tarsectomy  or  excision  of  particular  bones,  are 
needful ;  and  in  the  worst,  even  amputation  may  be  necessary  to  rid 
the  patient  of  a  hopelessly  deformed  limb,  which  is  not  only  use- 
less but  an  encumbrance.  In  paralytic  cases  it  is  obviously 
essential  to  encourage  by  friction,  douching,  and  galvanism  the 
nutrition  and  functional  activity  of  the  paralysed  muscles,  other- 
wise a  recurrence  of  the  deformxity  will  ensue. 

Even  when  a  talipedic  foot  has  been  by  one  or  other  means 
placed  in  its  correct  position,  the  patient  must  wear  some  form  of 
retentive  and  supporting  apparatus  for  at  least  three  or  four  years 
in  order  that  recurrence  may  be  prevented. 


TALIPES    CALCANEUS 

Talipes  calcaneus  is  a  rare  deformity  and  may  be  congenital  or 
acquired. 

Anatomy. — The  heel  is  depressed  and  the  anterior  muscles 
of  the  leg  and  anterior  ligament  of 
the  ankle  joint  are  contracted  and 
shortened.  The  astragalus  is  dis- 
placed somewhat  backwards,  and  if 
the  tarsal  arch  is  much  increased, 
there  will  be  some  degree  of  dis- 
placement at  the  medio-tarsal  joint, 
the  anterior  part  of  the  foot  being 
directed  downwards,  i.e.  there  is 
associated  pes  arcuatus  (p.  294), 
In  mild  and  early  cases  there  is  no 
increase  in  the  tarsal  arch,  the  sole 
remains  normal  and  the  toes  are 
not  elevated. 

The  soft  structures  over  the  heel 
are  much  thickened  and  a  false  bursa  may  develop. 

Treatment. — In  congenital  cases  shampooing  and  manipula- 


Fig.  87. — Talipes  calcaneus  (FolHn). 


MANUAL  OF  SURGERY 


CHAP. 


tion,  combined  with  the  use  of  a  malleable  iron  splint,  the  angle  of 
which  can   be   altered   as   improvement   is   effected,  may   effect  a 


Fig.  88.— Tubby's  modification  of  Thomas's  wrench. 


cure,   otherwise 


"  stop  " 
89). 


In     marked 


the  contracted  structures  must  be  divided.      The 
acquired   deformity,  when    slight,  may    similarly   be    treated    by  a 
mechanical  contrivance  ;    Tubby  recommends 
a  boot  with  a   toe -depressing    spring    and   a 
to    prevent   the   heel  dropping   (Fig. 

cases     the    contracted 

structures    will    require 

division,   and    the   foot 

may    then    be    forcibly 

wrenched      into      posi- 
tion ;    for  this  purpose 

Tubby's      modification 

of  Thomas's  wrench  is 

the     best      instrument 

(Fig.  88). 

In    paralytic     cases 

the  tendo  Achillis  may   ^     ^ 

^      r  iG.  59. — Walking  apparatus 
be   shortened.  for  talipes  calcaneus  w  ith 

toe  -  depressing        spring 
(Tubby). 


TALIPES    EQUINUS 

Talipes  equinus  is  practically  always  an 
acquired  deformity  and  varies  much  in 
degree.  The  position  of  T.  equinus  is 
sometimes  voluntarily  assumed  by  patients 
with  a  shortened  limb  in  order  to  bring  the  foot  to  the  ground. 
Normally  the  foot  can  be  dorsiflexed  to  an  angle  of  about  18°;  in 
T.  equinus  this  range  of  flexion  is  diminished.  In  the  mildest 
cases  the  foot  can  be  placed  at  a  right  angle  with  the  leg ;  in  the 
worst  it  is  fully  extended,  and  the  dorsal  aspect  of  the  toes  comes 


Fig.  90.— Talipes  equinus 
(Follin). 


XII  TALIPES  VALGUS  289 

in  contact  with  the  ground  so  that  walking  is  impossible  if  the 
deformity  is  bilateral ;  such  an  extreme  degree  is,  however,  rare, 
and  in  the  majority  of  cases  the  following  condition  will  be  found 
to  exist. 

Anatomy. — The  heel  is  raised,  owing  to  contraction  of  the 
.endo  Achillis,  so  that  the  patient  walks  on  the  heads  of  the  meta- 
tarsal bones.  This  position  leads  to  broadening  of  the  anterior  part 
of  the  foot  and  to  induration  of  the  skin  and  subcutaneous  tissue, 
with  the  formation  of  painful  corns  in  this  situation.  The  degree 
of  the  deformity  is  most  marked  when  the  knee  joint  is  extended. 
The  head  of  the  astragalus  is  necessarily  rendered  prominent,  and 
there  may  be  some  degree  of  subluxation  at  the  astragalo-scaphoid 
joint.  The  tarsal  arch  may  be  considerably  increased,  the  fascial 
structures  and  plantar  ligaments  being  shortened  and  the  dorsal 
stretched.  The  posterior  ligament  of  the  ankle  joint  is  shortened, 
and  the  peroneus  brevis  and  longus  and  flexor  tendons  may  be 
contracted ;  if  the  arch  of  the  foot  is  much  increased,  the  short 
plantar  muscles  are  also  contracted. 

Treatment. — In  slight  degrees  manipulation  and  moderate 
exercise,  combined  with  galvanism  to  the  muscles  in  paralytic  cases, 
will  usually  cure  the  deformity. 

When  this  is  more  marked,  the  tendo  Achillis  must  be  divided, 
and  the  plantar  fascia  may  require  similar  treatment.  After  teno- 
tomy the  limb  should  be  at  once  put  up  in  plaster  of  Paris  or  in  a 
Scarpa's  shoe  until  healing  is  complete. 


TALIPES    VALGUS 

Talipes  valgus  is  nearly  always  met  with  in  association  with  pes 
planus  (Fig.  97,  p.  295),  and  is  sometimes  due  to  absence  of  the 
fibula.  The  foot  is  everted,  and  the  arch  is  flattened,  owing  to 
yielding  at  the  medio-tarsal  articulation.  The  peronei  muscles 
are  contracted  and  shortened. 

Treatment. — If  manipulation  and  properly  constructed  boots 
(see  p.  296)  do  not  correct  the  deformity  the  peronei  must  be 
divided. 

TALIPES    VARUS 

Pure  talipes  varus  is  extremely  rare,  but  may  be  due  to  paralysis  of 
the   peronei.     The   foot   is   adducted    to   the   middle   line   and   is 
inverted  at  the  medio-tarsal  joint ;  the  toes  are  turned  inwards,  the 
VOL.  1  u 


290 


MANUAL  OF  SURGERY 


CHAP, 


Fig.  91. — Talipes  varus  (Follin). 


plantar  fascia  is  contracted,  and  the  arch  of  the  foot  is  increased. 

The  patient  walks  on  the  outer  border  of  the  foot. 

Treatment.  —  The  treatment 
of  the  condition  is  similar  to  that 
recommended  for  talipes  equino- 
varus. 

CONGENITAL    TALIPES    EQUINO- 
VARUS 

This  deformity  is  more  common 
in  boys  than  girls,  is  usually  bi- 
lateral, and  is  sometimes  associated 
with  other  deformities,  such  as 
spina  bifida.  It  varies  considerably 
in  degree.  In  the  mildest  cases  it 
can  be  reduced  by  manipulation, 
but  the  foot  assumes  the  unnatural 
position  as  soon  as  it  is  released. 
In  the  next  degree  complete  re- 
storation to  the  normal  cannot  be  effected  by  this  means,  and  in 
the  worst  form  the  foot  is  rigidly 
fixed  in  the  abnormal  position. 

Anatomy. — The  foot  is  ex- 
tended at  the  ankle  joint  and  the 
heel  is  drawn  up ;  the  sole  is  in- 
verted, the  toes  are  adducted  to 
the  middle  line  of  the  body,  the 
inner  border  of  the  foot  is  raised, 
and  the  foot  is  folded  on  itself  at 
the  medio-tarsal  joint.  The  great 
toe  is  flexed,  and  often  consider- 
ably adducted,  so  that  the  inter- 
digital  space  is  much  broadened. 
The  internal  malleolus  is  less,  and 
the  external  more  prominent  than 
usual.  If  the  child  is  old  enough 
to  have  walked,  the  deformity  is 
accentuated,    and    as    the    outer 

border     of    the     foot    (and     in    bad    ;  FiG.r92.— Congenital  ta'ipesequino-vanis 

cases    part   of   the    dorsum   also)  ^  "    ^^' 

comes  in  contact  with  the  ground,  the  skin  and  subcutaneous  tissue 


XII 


CONGENITAL  TALIPES   EQUIXO-VARUS  291 


are  much  thickened  and  hypertrophied,  and  false  bursae  and  corns 
form,  which  cause  considerable  pain,  and  may,  on  account  of  inflam- 
mation, make  walking  impossible.  In  the  sole  of  the  foot  there  is  a 
transverse  crease  opposite  the  medio-tarsal  joint,  and  from  this  a  longi- 
tudinal crease  runs  forwards  to  the  first  interdigital  space.  These 
creases  are  diagnostic  of  the  congenital  nature  of  the  deformity. 
The  tarsal  bones  are  altered  in  shape.  Owing  to  curvation  of  its 
neck,  the  head  of  the  astragalus  forms  a  marked  dorsal  prominence 
and  is  directed  downwards  and  inwards.  There  may  be  partial  luxa- 
tion at  the  mid-tarsal  joint.  The  osseous  deformity  becomes  more 
marked  as  growth  proceeds  and  when  the  child  begins  to  walk ; 
as  ossification  advances,  the  deformity  may  be  rendered  permanent. 
The  anterior  tibial  muscles  are  deflected  inwards,  and  those  behind 
the  inner  ankle  fonvards ;  the  peroneus  longus  tendon  grooves  the 
OS  calcis  instead  of  the  cuboid.  All  the  muscles  remain  un- 
developed and  tend  to  undergo  atrophy.  The  dorsal  ligaments, 
and  those  on  the  outer  border  of  the  foot,  are  lengthened  and 
attenuated,  while  those  on  the  inner  side  and  the  plantar  fascia  are 
contracted. 

Owing  to  the  nature  of  the  deformity  the  child  has  a  peculiar 
waddling  gait,  and  in  marked  cases  has  to  lift  one  foot  over  the  other 
{reel-feet). 

Treatment. — The  earlier  treatment  is  commenced  the  better, 
its  nature  depending  upon   the  degree  of  de- 
formity and  the  age  of  the  patient. 

In  the  least  severe  cases,  when  the  defor- 
mity can  be  overcome  by  manipulation,  this, 
combined  with  douching,  massage,  and  galvan- 
ism to  the  muscles,  should  be  conscientiously 
carried  out  two  or  three  times  a  day.  Manipu- 
lation must  be  gentle  and  steady,  and  the  foot 
must  be  everted  and  adducted  at  the  mid-tarsal 
joint,  and  also  flexed  at  the  ankle  joint. 
During  the  treatment  a  flexible  metal  splint,  or 
tin  shoe  with  a  movable  foot-piece,  should  be 
worn,  and  must  be  moulded  to  fit  the  outer 
side  of  the  leg  and  foot  to  correct  the  varus,  ~"-- 1--'' 

and  to  the  posterior  surface  of  the  leg  and  sole  Fig.  93. —  Tin  shoe  with 
of  the   foot   to  correct   the  equinus.      As  the        Seei  (Tub™-).^^"*"  *' 
position  of  the  foot  is  improved,  the  flexible 
metal  can  be  easily  adapted  to  the  shape  of  the  limb.      This  treat- 
ment, if  carefully  persevered  with,  will  correct  the  deformity ;  but 


292  MANUAL  OF  SURGERY  chap. 

the  retentive  apparatus  must  be  worn  for  many  months  to  prevent 
recurrence. 

In  more  severe  cases,  in  which  the  deformity  cannot  be  wholly 
reduced  by  manipulation,  tenotomy  should  be  performed,  and  the 
operation  may  be  undertaken  when  the  child  is  only  a  few  days  old. 
It  is  advisable  to  first  correct  the  varus  by  dividing  the  tibialis  pos- 
ticus, flexor  longus  digitorum,  and,  if  necessary,  the  tibialis  anticus 
and  extensor  proprius  hallucis  tendons,  together  with  the  plantar 
fascia.  At  a  later  date  the  equinus  may  be  overcome  by  division  of 
the  tendo  Achillis.  Tenotomy  and  fasciotomy  may  be  followed  by 
manual  or  instrumental  wrenching  in  order  to  correct  the  deformity. 
After  tenotomy,  the  foot  may  be  immediately  placed  in  a  plaster 
casing ;  but  if  the  normal  position  cannot  be  at  once  attained,  it  is 
better  practice  to  effect  gradual  reduction,  so  that  the  bones  may 
gradually  be  moulded  to  the  proper  position.  For  this  purpose 
Scarpa's  or  Little's  shoe  is  the  best  apparatus.  The  gradual  treat- 
ment must  be  conducted  over  a  period  of  about  two  months  to  over- 
come the  varus,  and  for  another  like  period  after  the  tendo  Achillis 
has  been  divided.  When  the  normal  or  best  position  has  been 
attained  by  these  means,  the  patient  should  wear  a  retentive  walking 
apparatus  for  three  or  four  years,  or  more,  in  order  to  prevent  relapse. 
During  the  first  year,  it  is  also  advisable  to  wear  a  light  apparatus 
at  night. 

In  the  worst  cases  the  above  treatment,  with  forcible  attempts 
at  rectifying  the  deformity  by  means  of  the  wrench,  may  give  a 
good  result,  provided  plenty  of  time  and  patience  be  expended  ;  but 
should  it  fail,  some  further  operative  measures  will  be  needed. 

Tarsotomy  and  tarseetomy. — These  operations  are  but  rarely 
called  for,  and  should  never  be  performed  on  young  children,  for  in 
them  milder  means  will  overcome  the  deformity.  Of  their  value  the 
opinions  of  surgeons  best  qualified  to  judge  vary  within  the  widest 
limits  ;  some  extol  these  operations,  while  others  decry  them  as 
almost  unjustifiable.  It  seems,  however,  that  the  truth  lies  between 
the  two  extremes ;  there  are  certainly  cases  in  which  no  other 
treatment  can  be  effective,  and  recourse  must  be  made  to  some  such 
form  of  operation  imperfect  though  its  results  may  be. 

Of  the  many  operations  which  have  been  devised,  the  removal 
of  the  astragalus  or  the  division  of  its  neck,  or  the  removal  of  a 
wedge-shaped  portion  of  the  tarsus  (the  base  being  at  the  outer 
border  of  the  foot),  are  those  of  the  greatest  value,  that  one  being 
given  the  preference  which  seems  most  suitable  to  the  case.  It 
must  not  be  forgotten  that  such  operations  are  by  no  means  free 


XII  ACQUIRED  TALIPES   EQUINO-VARUS  293 

from  danger,  especially  in  the  hands  of  those  not  well  acquainted 
with  the  details  of  operative  surgery,  and  that  even  the  most  brilliant 
result  leaves  much  to  be  desired.  While  it  is  quite  true  that  a 
shapely  foot,  the  sole  of  which  comes  upon  the  ground,  may  be 
secured,  yet  such  a  foot  is  better  in  appearance  than  in  fact,  for  it 
has  lost  many  of  the  characters — and  those  by  no  means  the  least 
important — of  the  normal  foot.  Thus  the  plantar  arch  is  more  or 
less  destroyed,  and  there  is  impairment  or  even  complete  fixity  at 
the  ankle  and  mid-tarsal  joints,  so  that  the  foot  has  lost  one  of  its 
most  characteristic  and  valuable  features — elasticity.  At  the  same 
time,  it  is  only  fair  to  state  that  such  operations  certainly  shorten  the 
time  taken  up  in  cure,  and  are  less  liable  to  be  followed  by  relapse ; 
but  should  such  unfortunately  occur,  nothing  further  can  be  done, 
and  amputation  is  the  only  means  of  ridding  the  patient  of  a  de- 
formed, useless,  and  often  painful  foot.  Amputation  is,  however, 
very  rarely  needed,  and  should  usually  be  reserved  for  those  cases 
in  which  suppuration  occurs  in  the  bursae  and  thickened  tissues  as 
the  result  of  prolonged  pressure  and  irritation. 


ACQUIRED    TALIPES    EQUINO-VARUS 

The  acquired  deformity  is  nearly  always  due  to  infantile  paralysis 
(Fig.  94)  affecting  the  peronei  and  muscles  on 
the  front  of  the  leg,  although  the  tibialis  anticus 
may  escape.  In  some  cases  the  deformity  is 
spastic,  and  in  a  few  is  dependent  upon  injury 
or  disease  about  the  ankle  joint  or  tibial  epi- 
physis. 

The  deformity  is  much  the  same  as  that  of 
congenital  origin  (Fig.  92,  p.  290);  but  the  heel 
is  often,  especially  in  spastic  cases,  more  raised, 
the  transverse  and  longitudinal  creases  on  the  sole 
are  wanting,  and  the  head  of  the  astragalus  is 
not  directed  inwards. 

The  paralysed  muscles  are  fatty  and  atrophied, 
while  the  others  are  tensely  contracted. 

Treatment. — In  paralytic   cases  the  treat-  Fig.  94.— Talipes  equino- 

^     1  r  .        .1  .    •    •  J  varus    from  infantile 

ment  must  have  reference  to  the  nutrition  and        paraivsis  in  a  child 
improvement  of  the  paralysed  muscles,  and  the        ^l^s  (Tu'bby).  ^  ^^^^ 
rectification  of  the  deformity.      These  aims  may 
be  carried  into  effect  by  douching,  friction,  galvanism,  and  manipu- 
lation,   combined  with  tl"ie  use  of  a   tin  shoe  or  malleable   splint 


294 


MANUAL  OF  SURGERY 


CHAP. 


(Fig.   93,   p.  291),   as  recommended  for  the  congenital  deformity. 
Tenotomy  must  be  performed  if  needful. 


TALIPES    CAVUS 

Talipes  cavus  is  usually  an  acquired  deformity  due  to  weakness 
of  the  anterior  muscles  of  the  leg,  and  is 
often  associated  with  slight  talipes  equinus. 
Anatomy. — The  arch  of  the  foot  is 
increased,  and  the  plantar  fascia  is  con- 
tracted.    The    anterior    tibial  muscles    are 

tense,  so  that  the 
metatarso-phalangeal 
joints  are  over-ex- 
tended, while  the 
inter  -  phalangeal 
joints  are  flexed. 
The  tendo  Achillis 
is  slightly  contracted. 
According  to  some 
the  condition  is 
primarily  due  to 
paralysis  of  the  lumbricales,  interossei,  and  short  flexors  of  the 
great  toe ;  while  others  consider  that  it  is  a  compensatory  change  to 
slight  T.  equinus,  the  arch  being  increased  so  that  the  heel  may 
come  to  the  ground.  If  the  balls  of  the  toes  are  on  the  same  level 
as  the  heel  the  condition  is  spoken  of  as 
T.  arcuatiis  (Fig.  95),  but  when  they  are 
depressed  to  a  lower  level  as  T.  platttaris 
(Fig.  96).  There  is  considerable  incon- 
venience in  walking,  and  often  pain, 
owing   to   the   formation   of 


Fig.  95. — Talipes  arcuatus  in  a  boy  aged  five  and  a  half  years 
(Tubby). 


corns  on  the  sole  opposite 
the  heads  of  the  metatarsal 
bones — especially  the  first 
and  fifth. 

Treatment.  —  The 
equinus  must  be  corrected 
by  division  of  the  tendo 
Achillis ;  the  plantar  fascia 
and  extensor  tendons  will  also  need  division.  The  foot  should 
then  be  carefully  put  up  on  a  back  spHnt  with  a  foot-piece,  and  the 


Fig.  96. — Talipes  plantaris  (Tubby). 


XII 


PES  PLANUS— FLAT  OR   SPLAY  FOOT 


295 


position  maintained  for  a  month  or  more,  daily  manipulation  being 
employed  after  ten  days.  The  treatment  is  sometimes  disappoint- 
ing, especially  in  unskilled  hands,  and  a  second  operation  may  be 
necessary. 

TALIPES    CALCANEO-VALGUS 

Talipes  calcaneo-valgus  is  a  rare  form  of  club-foot,  and  may  be 
congenital  or  acquired  as  the  result  of  infantile  paralysis. 

Anatomy. — The  heel  is  depressed,  and  the  outer  border  of  the 
foot  is  everted  and  raised,  the  part  in  front  of  the  mid-tarsal  joint 
being  abducted.  The  sole  is  flattened.  The  anterior  tibial  and 
peroneal  muscles  are  contracted,  and  the  ligaments  on  the  outer 
side  of  the  foot  are  shortened. 

Treatment. — Rectification  of  the  deformity  may  be  effected 
by  manipulation,  douching,  etc.,  combined,  if  needful,  with  division 
of  the  contracted  tendons. 


PES  PLANUS FLAT  OR  SPLAY  FOOT 

Pes  planus  is  usually  associated  with  more  or  less  T.  valgus 
and  is  congenital  or  acquired.  In  the  latter  case  the  condition 
may  be  due  to  rickets,  and  is  often  associated  with  genu  valgum. 
Flat  foot  often  makes  its  appearance,  or  at  least  increases  in 
severity,  about  the  age  of  puberty — that  is,  at  a  time  when  growth 
is  rapid,  and  the  naturally  weak  arch  may  yield  from  laxity  of  its 


Fig.  97. — Pronounced  flat  foot  (Tubby). 


ligamentous  supports  owing  to  the  rapidly  increasing  weight  of  the 
body.     This  is  especially  likely  to  occur  in  those  who  are  naturally 


296 


MANUAL  OF  SURGERY 


CHAP 


weak  and  feeble,  who  are  recovering  from  some  severe  illness,  or 
whose  occupation  {e.g.  waiters)  entails  long  hours  of  standing. 

Anatomy. — Owing  to  the  loss  of  the  longitudinal  and  trans- 
verse arches  the  foot  becomes  proportionately  lengthened  and 
broadened ;  the  inner  border  is  convex,  thicker  than  natural,  and 
rests  upon  the  ground,  and  the  portion  of  the  foot  in  front  of  the 
mid-tarsal  joint  is  everted  and  abducted  (Fig.  97,  p.  295).  The 
inferior  calcaneo-scaphoid  ligament,  on  which  the  head  of  the 
astragalus  rests,  is  stretched  and  the  plantar  fascia  yields,  so  that  the 
head  of  the  bone  and  the  scaphoid  are  displaced  downwards  and  in 
bad  cases  may  rest  upon  the  ground.  The  tibialis  posticus  tendon 
is  weakened,  and  the  anterior  and  posterior  leg  muscles  tend  to  waste, 
while  the  peronei  are  contracted  and  often  in  a  state  of  spasm. 

The  patient's  gait  is  shuffling  and  shambling,  and  progression  is 
slow ;  fatigue  is  soon  induced,  and  there  is  considerable  pain, 
especially  beneath  the  astragalo-scaphoid  joint.  The  foot  sweats 
easily  and  becomes  puffy  at  night,  especially  if,  as  is  often  the  case, 
the  veins  are  congested  or  varicose. 

Treatment. — Complete  rest  for  two  or  three  weeks  is  essen- 
tial ;  it  alleviates  the  pain  and  diminishes  the  spasm  of  the  peronei 
muscles;  during  this  time  shampooing,  cold  douching,  and  manipula- 
tion will  do  much  good. 

In  mild  cases  the  patient  should  have  a  Whitman's  valgus  sole- 
pad  fitted  to  the  boots,  which  raises  the  inner  border  and  helps  to 

sustain  the  weakened  arch,  which 
may  be  further  strengthened  by 
directing  the  patient  to  raise 
himself  on  to  the  tips  of  his 
toes  as  a  means  of  exercise, 
and  should  be  employed  two 
or  three  times  daily  for  as  long 
a  time  as  the  strength  of  the 
muscles  will  permit  without 
pain  or  fatigue.  If  it  be  found 
that  in  spite  of  rest  the  peronei 
remain  contracted  [the  tendons 
should  be  divided,  and  gradual 
replacement  may  be  then  effected  by  the  use  of  Scarpa's  shoe  and 
daily  manipulation.  Wrenching  the  foot  under  an  anaesthetic  and 
confinement  in  a  plaster  casing  for  three  or  four  weeks,  followed 
by  daily  manipulation,  is  often  serviceable. 

In   very   bad   cases,  where   no  good  can  be  effected  owing  to 


Fig.  98. — Whitman's  valgus  sole-pad  applied 
(Tubby). 


XII  TENOTOMY  297 

arthritic  changes,  the  astragalo-scaphoid  joint  may  be  excised,  and 
the  bony  surfaces  united  by  suturing  or  pegging  after  the  foot  has 
been  placed  in  a  good  position  by  forcible  manipulation  ;  it  is  then 
put  up  in  plaster,  and  the  patient  is  not  allowed  to  put  it  to  the 
ground  for  three  or  four  months,  i.e.  until  the  ankylosis  between 
the  bones  is  sound  enough  to  sustain  the  necessary  weight.  Such 
treatment  is,  however,  very  tedious,  and  few  patients  can  afford  the 
time. 


TENOTOMY 

The  division  of  tendons,  ligaments,  and  tense  bands  of  fasciae 
may  be  necessary  for  the  correction  of  congenital  or  acquired 
deformities.  The  operation  may  be  performed  by  the  open  or 
subcuta7ieous  method ;  the  former  should  always  be  used  in  the  case 
of  the  sterno-mastoid  in  view  of  its  dangerous  relations,  and  may 
also  be  employed  for  the  biceps  femoris  if  the  surgeon  feels  uneasy 
about  the  peroneal  nerve ;  with  due  antiseptic  precautions  the 
open  method  is  as  safe  as  the  subcutaneous. 

The  subcutaneous  operation. — The  subcutaneous  operation 
maybe  performed  in  two  ways:  (i)  by  cutting  the  tendon  from 
within  out;  or  (2)  from  without  in;  in  the  first  method  the  knife  is 
placed  beneath  the  tendon,  and  in  the  second  between  it  and  the 
skin ;  the  method  to  be  selected  depends  upon  the  situation  of  the 
tendon.  The  patient  is  anaesthetised,  and  the  part,  e.g.  the  foot,  is 
held  by  an  assistant  in  such  a  position  as  will  relax  the  tendon  to 
be  divided ;  the  surgeon  then  passes  the  narrow-bladed  sharp- 
pointed  tenotome  deep  or  superficial  to  the  tendon  according  to 
the  method  he  adopts.  This  is  withdrawn,  and  replaced  by  the 
blunt-pointed  instrument.  The  knife  is  passed  on  the  flat,  and 
the  cutting  edge  is  then  turned  towards  the  tendon  which  is  divided 
by  slight  sawing  cuts,  while  the  assistant  steadily  draws  the  foot 
into  that  position  which  renders  the  tendon  tense.  When  the 
division  is  completed  the  tendon  parts  with  a  sudden  snap  ;  any 
tense  bands  which  can  be  felt  should  be  divided,  but  in  the  case  of 
the  biceps  femoris  this  should  never  be  done,  a  tense  band  will 
always  be  felt — it  is  the  peroneal  nerve.  The  small  skin  puncture 
is  closed  with  a  pad  of  wool  and  collodion, 

Rectifieation  of  the  position. — After  tenotomy  or  fasciotomy 
the  abnormal  position  necessitating  the  operation  may  be  at  once 
completely  rectified,  or  adjustment  may  be  postponed  for  a  week  or 
ten  days,  or  may  be  gradually  effected.     As  a  rule,  it  may  be  said 


298  MANUAL  OF  SURGERY  chap. 

that  gradual  reposition  is  the  best,  and  should  always  be  carried 
out  if  the  tendon  on  division  is  separated  by  a  gap  of  an  inch  or 
more,  if  the  open  method  has  been  resorted  to,  or  if  a  vessel  or 
nerve  of  importance  has  been  damaged. 

Dangers  of  the  opepation. — In  passing  the  knife  care  must 
be  taken  that  the  tendon  is  not  transfixed,  or  it  will  only  be  partially 
divided.     Should  this  happen  the  knife  must  be  re-introduced. 

If  an  artery  be  wounded,  as  may  occur  to  the  posterior  tibial 
during  division  of  the  tibialis  posticus  and  flexor  longus  digitorum 
tendons,  the  accident  will  be  recognised  by  a  sudden  spurt  of 
blood  by  the  side  of  the  knife  and  by  blanching  of  the  foot 
Under  such  circumstances  it  is  necessary  to  apply  a  pad  and 
bandage,  and  postpone  all  attempts  at  reposition  of  the  foot  for 
about  a  fortnight.  Division  of  a  nerve  would  necessitate  laying 
open  the  wound,  and  thus  converting  the  subcutaneous  into  an  open 
operation,  in  order  that  immediate  suture  may  be  performed. 

Suppuration  after  tenotomy  ought  never  to  occur  if  due  pre- 
cautions have  been  taken. 

Non-union  of  a  tendon  may  result  if  suppuration  follows  the 
operation,  or  if  the  separation  between  the  cut  ends  is  great,  and 
has  been  further  increased  by  immediate  reduction  of  the  deformity. 

Tenotomy  of  the  tibialis  anticus  tendon  is  usually  per- 
formed just  before  the  tendon  reaches  the  internal  cuneiform  bone. 
The  knife  is  passed  beneath  the  tendon  from  the  outer  side,  so  as 
to  avoid  the  anterior  tibial  artery. 

Tenotomy  of  the  extensors  of  the  toes  may  be  per- 
formed on  the  individual  tendons  about  a  finger's  breadth  ^  behind 
the  heads  of  the  metatarsal  bones ;  the  knife  may  safely  be  passed 
superficial  to  the  tendon,  which  is  divided  while  the  toes  are  forcibly 
flexed. 

Tenotomy  of  the  tibialis  posticus  and  flexor  longus 
digitorum. — The  leg  is  placed  on  the  outer  side,  and  the  knife 
is  passed  between  the  tendons  and  the  bone  about  two  fingers' 
breadth  above  the  small  tubercle  which  can  be  felt  near  the  base  of 
the  internal  malleolus.  Care  must  be  taken  that  the  knife  is  not 
thrust  too  deeply,  or  the  posterior  tibial  artery  may  be  wounded. 

The  tendo  Achillis  is  divided  just  above  its  insertion,  at  its 
narrowest  part.  The  knife  may  be  passed  superficial  to  the  tendon 
which  is  divided  inwards ;  there  is  practically  no  risk  of  wounding 
the  posterior  tibial  artery  if  care  is  taken,  but  owing  to  its  proximity 

^  It  must  be  remembered  that  when  distance  is  measured  by  fingers'  breadth,  the 
finger  must  be  that  of  the  patient,  not  of  the  operator. 


XII  FASCIOTOMY— SYNDESMOTOMY  299 

many  surgeons  prefer  to  divide  the  tendon  from  its  deep  sur- 
face. 

The  peroneus  longus  and  brevis  are  cut  about  three 
fingers'  breadth  above  the  base  of  the  external  malleolus,  the  knife 
being  passed  between  the  tendons  and  the  bone. 

The  biceps  femoris  is  best  divided  by  the  open  method,  so 
that  all  danger  of  wounding  the  peroneal  nerve,  which  lies  just 
internal  to  it,  is  avoided.  If  the  subcutaneous  method  is  employed 
the  knife  is  passed  to  the  inner  side  of  the  tendon,  i.e.  between  it 
and  the  nerve,  and  the  tendon  is  divided  outwards ;  when  the 
division  is  complete  the  nerve  will  be  felt  as  a  tense  rounded  cord. 

The  semi-membranosus  and  semi-tendinosus  should  be 
divided  from  the  deep  surface  just  above  the  internal  condyle. 

The  sterno  -  mastoid  must  be  cut  by  the  open  method 
(see  p.  277). 

FASCIOTOMY 

Fasciotomy  or  division  of  tense  bands  of  fascia  is  necessitated 
for  the  cure  of  Dupuytren's  contraction  of  the  fingers  (p.  307),  and 
for  some  forms  of  club-foot. 

The  plantar  fascia  is  best  divided  by  passing  the  knife  be- 
neath the  skin  and  superficial  to  the  fascia.  The  point  of  division 
and  the  number  of  punctures  for  the  division  of  individual  bands 
of  fascia  must  be  determined  on  the  merits  of  the  case ;  sometimes 
numerous  punctures  are  necessary.  Complete  removal  of  the  fascia 
by  the  open  method  is  recommended  by  some  surgeons. 

SYNDESMOTOMY 

Syndesmotomy  or  division  of  ligaments  is  occasionally  necessary 
in  cases  of  club-foot ;  Parker's  astragalo-scaphoid  capsule  (formed 
by  blending  of  the  ligaments)  sometimes  requires  division  in  casts 
of  unyielding  talipes  equino-varus.  This  capsule  can  be  divided, 
in  association  with  the  tibial  tendons,  at  a  point  just  in  front  of  and 
on  a  slightly  lower  level  than  the  tip  of  the  internal  malleolus.  The 
knife  is  entered  beneath  the  skin,  and  cuts  all  structures  down  to 
the  bone. 

GENU    VALGUM 

Varieties  and  causation. — Genu  valgum  may  be  rachitic, 
static,  or  pathological.     The  rachitic  form  occurs  in  young  children, 


300  MANUAL   OF  SURGERY  chap. 

and  is  due  either  to  bending  of  the  soft  rickety  bones,  the  femur  in- 
wards and  the  tibia  outwards,  or  to  unequal  grov\-th  at  the  epiphysary 
Hne,  leading  to  disproportionate  length  of  the  internal  condyle,  either 
because  this  has  grown  inordinately,  or  because  the  external  condyle 
has  ceased  to  develop  from  premature  ossification  of  its  epiphysary 
line. 

Static  genu  valgum  becomes  manifest  at  or  about  the  age 
of  puberty,  and  is  sometimes  predisposed  to  by  early  rachitic 
changes,  but  may  occur  quite  independently  of  that  disease.  It  is 
dependent  upon  the  habitual  assumption  of  that  position  of  rest  in 
which  the  main  weight  of  the  body  is  thrown  on  the  internal  lateral 
ligament  and  the  sole  of  the  foot,  and  hence  these,  being  unable  to 
bear  the  long-continued  strain,  eventually  yield ;  the  knee  goes 
inwards  and  the  arch  of  the  foot  is  flattened  (pes  planus).  The 
associated  flat  foot  aggravates  the  genu  valgum,  which  is  still  further 
increased  and  rendered  permanent  by  the  fact  that  the  internal 
condyle,  being  to  some  extent  relieved  of  pressure,  grows  more 
quickly  than  the  external,  and  becomes  elongated.  After  a  timxC 
the  external  lateral  ligament,  the  biceps  tendon,  and  the  ilio-tibial 
band  become  somewhat  shortened  and  contracted.  The  tibia  is 
rotated  outwards,  and  the  patella  is  more  or  less  displaced  to  the 
same  side. 

The  pathological  causes  of  genu  valgum  must  be  sought  in  in- 
flammation of  or  injury  to  the  epiphyses,  in  infantile  paralysis,  or 
fracture  of  the  lower  end  of  the  femur  or  upper  end  of  the  tibia; 
genu  valgum  from  these  causes  is  rare  and  usually  slight  in  degree. 

Sig'ns. — There  is,  especially  in  women,  a  natural  tendency  to 
knock-knee  in  consequence  of  the  breadth  of  the  pelvis.  Slight 
degrees  are  but  little  noticeable,  but  when  the  condition  is  marked 
the  patient  walks  with  an  awkward,  rolling,  shambling  gait,  progresses 
slowly,  and  may  knock  together  or  cross  the  knees,  so  that,  when 
young,  he  not  infrequently  falls.  Fatigue  is  easily  induced,  and  there 
is  often  considerable  aching  in  the  legs  after  exertion  or  at  night. 
To  estimate  the  degree  of  deformity  the  patient  must  be  directed  to 
stand  up  with  the  knees  about  half  an  inch  apart ;  in  this  position 
the  malleoli  should,  if  the  legs  be  normal,  be  in  contact,  and  hence 
the  degree  of  genu  valgum  can  be  estimated  by  the  distance  they 
are  separated.  If  the  legs  be  flexed  the  deformity  disappears  prob- 
ably because  the  posterior  surfaces  of  the  condyles  of  the  femur  are 
but  little  aff'ected,  and  hence  at  this  point  the  axis  of  articulation  is 
practically  normal 

Treatment. — The   rachitic   form   may,   as   the   initial   disease 


XII 


GENU  VALGUM 


301 


becomes  cured  under  treatment,  considerably  improve,  especially  if 
manipulation  be  properly  carried  out ;  indeed,  in  slight  cases  the 
child  may  eventually  show  no  signs  of  the  deformity.  In  addition 
to  the  dietary  and  tonic  treatment  indicated  by  the  rickets  (chap.  v. 
vol.  iii.),  the  child  should  not  be  allowed  to  walk,  and  if  he  cannot 
be  kept  quiet  otherwise  an  outside  splint  reaching  below  the  sole 
must  be  put  on  each  leg,  so  that  it  is  impossible  for  him  to  stand ; 
such  a  splint,  moreover,  may  be  used  to  correct  the  deformity,  a 
pad  passing  round  the  inner  side  of  the  knee  being  used  to  gradually 
draw  it   outwards.     In   slight  cases  no  mechanical  appliances  are 


Fig.  99. — Genu  valgum  (Follin.  after  Macewen). 

needful,  but  night  and  morning,  after  cold  douching  and  massage  to 
the  limb,  gentle  manipulation  should  be  employed  with  the  view  of 
correcting  the  deformity ;  the  force  used  must  be  moderate,  and 
should  not  be  sufficient  to  cause  pain.  In  some  cases  it  may  be 
advisable  to  divide  the  shortened  and  contracted  tendinous  and 
fascial  bands  on  the  outer  side  of  the  joint. 

The  static  form  must  be  rectified  by  correcting  the  faulty 
habit  of  standing  which  occasions  it,  and  also -by  treating  the  pes 
planus. 

Operation  becomes  necessary  if  the  deformity  cannot  be  over- 
come by  manipulation  and  the  m.easures  above  indicated,  and  is  of 
such  a  degree  as  to  be  noticeable  or  inconvenient.  In  cases  where 
the  elongation  of  the  inner  condyle,  and  the  bending  of  the  femur 


302 


MANUAL   OF  SURGERY 


CHAP. 


and  tibia   is  pronounced,   operation  will  be  required.      Operative 

interference  is  also  indicated  in  children  over  four  or  five  years  of 

age  when  no  further  treatment  by  other  means  is  likely  to  prove 

beneficial. 

Osteotomy. — Of  the  various  operations  for  osteotomy  in  cases 

of  genu  valgum  that  devised  by  Macewen  is  most  in  favour.      It  is 

thus  performed  : — 

A  small  incision  is  made  down  to  the  bone  just  above  and  a 

little  in  front  of  the  adductor  tubercle  on  the  internal  condyle  of 
the  femur ;  the  chisel  is  then  introduced,  and 
is  turned  at  right  angles  to  the  shaft  of  the 
femur,  the  leg  resting  on  its  outer  side  on  a 
sand-bag.  By  a  few  strokes  of  the  mallet  the 
inner  and  anterior  two-thirds  of  the  bone  are 
divided,  and  the  remainder  is  broken  by  steadily 
bending  the  extended  limb  to  the  inner  side. 
The  superficial  wound  is  closed,  and  the  limb 
fixed  on  a  back  splint  for  ten  days,  when  the 
wound  will  be  found  soundly  healed ;  the  limb 
must  now  be  put  up  in  a  plaster  casing,  which 
may  be  removed  in  about  six  weeks,  and  the 
patient  be  allowed  to  get  about  on  crutches. 
If  the  tibia  is  much  curved  it  may  be  necessary 
to  divide  it  just  below  the  epiphysary  line  if  the 
osteotomy  of  the  femur  does  not  correct  the 
deformity ;  the  contracted  structures  on  the 
outer  side  may  also  need  division. 

Sir   William    MacCormac  recommends  that 

the  osteotomy  should  be  made  from  the  outer 

^,  side,    about    three   fin2;ers'    breadth    above   the 

Fig.  ioo.  —  1  he  same  case  .        '-^. 

as  Fig.  99,  p.  301,  after  patella;  the  Operation  is  conducted  as  already 

osteotomy.  described,  and  the  after-treatment  is  the  sam.e. 

The  advantages  claimed  for  this  procedure  are  that  the  bone  is 

divided  at  its   narrowest    part    and    at    some    distance    from    the 

epiphysary  line. 

Ogston's  operation  consists  in  making  a  small  wound  just  above 
the  inner  condyle,  and  then  introducing  a  saw  obliquely  in  front  of 
the  internal  condyle  to  the  intercondylar  notch ;  the  condyle  is 
then  sawn  off  obliquely,  and  as  the  leg  is  drawn  into  place  it  slips 
further  upwards.  This  method  is  useful  when  the  elongation  of 
the  condyle  is  the  chief  anatomical  defect,  but  it  has  the  dis- 
advantage of  opening  the  knee  joint,  and  is  now  rarely  performed. 


Xlt 


GENU   RECURVATUM 


303 


BOW-LEGS 

In  bow-lcgs  there  is  a  curvature  of  the  tibi?e  and  fibulae  out- 
wards and  forwards  which  is  commonly  the  result  of  rickets.  The 
curvature  is  usually  most  marked  in  the  lower  half  of  the  legs. 

Treatment. — Rickety  children  should  be  prevented  standing  so 
that  the  soft  bones  may  not  yield.  When  the  bones  are  sufficiently 
pliable  the  deformity  may  be  overcome  by  careful  manipulation  and 
a  splint  may  be  placed  on  the  inner  side  of  the  leg,  i.e.  on  the  con- 
cave side  of  the  curve.  In  bad  cases  when  the  child  is  over  four  or 
five  years  of  age  and  no  hope  of  cure  can  be  expected  by  the  above 
means  osteotomy  of  the  tibia  should  be  performed.  An  incision  is 
made  along  the  crest  of  the  tibia,  and  the  saw  is  then  introduced  to 
its  inner  side ;  when  the  bone  has  been  divided  the  fibula  is  broken 
and  the  deformity  forcibly  reduced.  The  wound  must  be  antisepti- 
cally  dressed  and  the  Hmb  placed  on  a  back  splint  with  a  foot-piece 
for  ten  days,  when  the  wound  will  be  found  healed ;  a  plaster 
casing  must  be  applied  for  another  three  or  four  weeks  to  allow  firm 
union  of  the  bones  to  occur. 


GENU    VARUM BANDY-LEGS 

Genu  varum  is  dependent  on  rickets  and  consists  in  an  outward 
bend  of  the  legs  due  to  curving  of  the 
lower  end  of  the  femur,  the  upper  ends 
of  the  tibia  and  fibula  and  the  knee  joint. 
The  external  condyle  of  the  femur  is 
longer,  and  in  the  internal  shorter  than 
natural,  and  the  ligamentous  and  ten- 
dinous structures  on  the  inner  side  of 
the  joint  may  be  shortened.  The  treat- 
ment is  conducted  on  the  same  lines  as 
for  genu  valgum. 

GENU    RECURVATUM 

Over-extension  at  the  knee  joint  may 
be  a  congenital  condition  or  may  result 
from  rickets,  infantile  paralysis,  or  after  a 

bad  excision  of  the  knee  joint.        A  slight      Fig.  101.— Genu  varum  of  rachitic 

degree  is  common,  but  marked  deformity       °"g^"  ('^"^^■">''  ^^^^'  "^^^^^^y 
rare.     If  it  cannot  be  remedied  by  manipulation  and  an  anterior 


304 


MANUAL   OF   SURGERY 


CHAP. 


splint,  division   of  the  tense  lateral  ligaments  may  be  required, 
bad  cases  resection  of  the  joint  may  be  undertaken. 


In 


HALLUX    VALGUS 

Hallux  valgus  is  more  frequent  among  women  than  men,  and  is 
usually  due  to  wearing  short  and  pointed  boots  which  crowd  the 

toes  together  and  deflect  the  great 
toe  towards  the  middle  line  of  the 
foot.  The  displaced  toe  rides  over 
or  under  the  second,  and  in  the 
former  case  there  may  be  associated 
hammer- toe.  The  head  of  the 
metatarsal  bone  and  base  of  the 
first  phalanx  form  a  prominence  on 
the  inner  side  of  the  foot  which  is 
covered  by  a  bursa  and  dense  hard 
skin  which  may  be  the  seat  of  a 
^  painful  corn.  The  bursa  may  in- 
flame and  suppurate  and  lead  to 
disease  of  the  bone  beneath  or  to 
destructive  arthritis  (Fig.  102). 
The  ligaments  and  muscles  on 


inner    side    of    the    toe    are 


Fig.  102.  —  Hallux  valgus  with  a  bursa 
over  the  nietacarpo  -  phalangeal  joint. 
The  bursa  has  inflamed  and  burst  (a),    the 

Stretched  and  lengthened,  and  those 
on  the  outer  side  proportionately  shortened ;  the  extensor  proprius 
hallucis  is  deflected  towards  the  middle  line,  and  is  rendered  tense, 
so  that  it  tends  to  increase  or  at  least  maintain  the  deformity. 
Hallux  valgus  may  be  associated  with  osteo-arthritis,  which  increases 
the  deformity.  The  condition  is  usually  bilateral,  although  worse 
on  one  side  than  the  other.  The  patient  complains  of  pain  in 
walking  and  consequent  lameness  which  becomes  much  more 
marked  if  the  bunion  inflames. 

Treatment. — In  slight  cases  the  deformity  may  be  rectified  if 
the  patient  will  wear  properly-made  boots.  Digitated  socks  are  also 
to  be  recommended,  and  some  advise  the  use  of  a  toe-post  between 
the  first  and  second  toes.  Cold  douching  and  manipulation  should 
be  employed  night  and  morning.  In  bad  cases  an  operation  must 
be  undertaken.     A  very  successful  procedure  is  as  follows : — 

The  bursa  is  carefully  dissected  away,  the  tendon  of  the 
extensor  proprius  hallucis  is  divided,  and  the  head  of  the  metatarsal 
bone  is  removed.     Some  surgeons  advise  resection  of  the  joint  or 


XII 


INGROWING  TOE-NAIL 


305 


siirplc  division  of  the  neck  of  the  metatarsal  bone.  The  wound 
must  be  aseptically  dressed  and  the  toe  kept  in  its  proper  position 
{i.e.  the  inner  border  in  a  line  with  that  of  the  fool)  by  a  splint. 

HALLUX    RIGIDUS HALLUX    DOLOROSUS 

Hallux  rigidus  consists  in  flexion  of  the  toe  at  the  metatarso- 
phalangeal joint.  It  usually  occurs  in  men  who  wear  short  and 
stiff  boots,  and  is  often  associated  with  flat  foot.  The  head  of  the 
metatarsal  bone  projects  towards  the  sole  and  a  bursa  may  form  over 
it.  There  is  considerable  pain,  especially  if  any  attempt  is  made  to 
extend  the  toe ;  rigidity  is  usually  due  to  matting  of  the  tendons 
and  periarticular  structures  as  the  result  of  inflammation,  but  it  is 
by  no  means  constantly  present. 

The  treatment  consists  in  wearing  pnpper  boots  and  correcting 
the  flat  foot ;  if  this  proves  ineflectual,  the  head  of  the  metatarsal 
bone  should  be  removed. 


INGROWING    TOE-NAIL 

This  painful  condition  is  usually  met  with  in  those  w^ho  wear 
tight  boots,  and  may  be 
brought  about  by  cutting 
the  nail  short  and  square 
so  that  a  sharp  angle  is 
left  which  irritates  the  soft 
structures.  These  in- 
flame and  ulcerate,  and 
a  foul  discharge  escapes 
from  beneath  the  granu- 
lating edge  which 
grows  up  over  the  nail. 
The  condition  nearly 
always  affects  the  great 
toe,  and  is  frequently 
bilateral.  Somewhat 
similar  trouble  is  some- 
times met  wdth  affecting  the  fingers.  The 
nail  is  broad,  and  inflammation  of  a  very 
intractable  nature  occurs  about  its  bed ;  the 
end  of  the  finger  becomes  clubbed,  inflamed, 
ulcerated,  and  tender  (onychia  "maligna,"  Fig.  104). 

VOL.  I  .„. 


Fig.  103.  —  Ingrowing  tfe- 
nail.  a,  the  area  of  in- 
flammation of  the  so't 
structures  ;  b,  line  of  the 
interphalangeal  articu- 
lation.    (Follin.) 


Fig.  104. 

Onychia  "maligna' 

(Fergusson). 


lo6 


MANUAL  OF  SURGERY 


CHAP. 


Treatment. — Slight  cases  of  ingrowing  toe-nail  may  be  much 
relieved  if  the  nail  be  well  pared  down  at  the  side  and  the  surface 
scraped  so  that  it  is  made  thinner.  In  troublesome  cases  half  the 
nail  should  be  removed  under  gas.  A  director  is  pushed  beneath 
it  and  it  is  slit  up,  and  the  half  on  the  affected  side  is  then  torn 
out  with  forceps.  The  granulating  area  at  the  side  should  be  cut 
away  and  a  gauze  dressing  be  applied  for  a  few  days.  Onychia  of 
the  fingers  requires  similar  treatment. 


HAMMER-TOE 

Hammer-toe  usually  affects  the  second  toe  and  is  bilateral ;  it 
may  be  congenital  and  seems  to  be  hereditary.  It  is  sometimes 
associated  with  and  caused  by  hallux  valgus,  the  great  toe  riding 
over  the  second. 

The  metatarso-phalangeal  joint  is  hyper-extended  (dorsi-flexed), 

the  second  phalanx  is 
/.?  flexed,  and  the  third  is 
usually  in  a  line  with 
the  second ;  the  head  of 
the  metatarsal  bone  is 
prominent  in  the  sole. 
On  the  dorsal  aspect  of 
the  first  interphalangeal 
joint  the  skin  is  thickened 
and  is  often  the  seat  of 
a  painful  corn,  beneath 
which  is  a  bursa ;  the 
end  of  the  toe  coming  in 
contact  with  the  ground  is 
broadened  and  flattened 
out,  and  a  corn  is  pre- 
sent which  causes  the 
pain  and  lameness  of 
which  the  patient  com- 
plains. The  lateral  and 
glenoid  ligaments  are 
shortened  and  thus  keep 
the  toe  in  its  abnormal  position ;  after  a  time  the  tendons  are  also 
contracted. 

Treatment. — In  slight  cases  daily  manipulation  and  wearing 
proper  boots  will  overcome  this  painful  deformity.     In  bad  cases 


Fig.  105. — Hammer-toe  (Tubby). 


XII  DUPUYTREN'S  COxNTRACTION  307 

operation  is  required.  A  fine  fascia  knife  is  inserted  in  the  middle 
line  of  the  plantar  aspect  opposite  the  first  interphalangeal  joint, 
and  being  turned  to  either  side  divides  the  contracted  flexor 
tendons  and  the  lateral  ligaments ;  care  must  be  taken  to  avoid  the 
digital  vessels  and  nerves  if  possible.  When  the  toe  has  been 
straightened  it  must  be  kept  in  its  proper  position  by  a  splint. 
Other  procedures  consist  in  excision  of  the  head  of  the  first 
phalanx  or  excision  of  the  joint ;  amputation  is  rarely  necessary, 
but  is  often  resorted  to  as  a  speedy  method  of  giving  relief. 


WEBBED    FINGERS    AND    TOES SYNDACTYLISM 

The  fingers  are  more  frequently  webbed  than  are  the  toes ;  two 
or  more  may  be  united.  The  bond  of  union  usually  consists  of 
skin  and  subcutaneous  tissue  only,  but  the  tendons  may  also  be 
fused  ;  in  the  worst  cases  (and  these  are  not  amenable  to  operation) 
the  bones  are  also  joined. 

The  web  may  be  short  or  extend  the  whole  length  of  the  digit. 

The  deformity  may  be  corrected  by  dissecting  up  two  flaps  — 
one  from  the  dorsal,  and  the  other  from  the  palmar  aspect  in 
opposite  directions ;  the  fingers  are  thus  separated  and  the  flaps, 
which  must  be  carefully  planned  so  that  no  raw  surface  is  left,  are 
stitched  in  position. 


SUPERNUMERARY    FINGERS    AND    TOES POLYDACTYLISM 

Supernumerary  fingers  and  toes  are  usually  imperfectly  developed, 
and  may  have  no  skeleton.  They  are  often  hereditary.  Amputa- 
tion should  be  performed. 


DUPUYTREN  S    CONTRACTION 

Dupuytren's  contraction  is  more  common  in  males  than  females, 
and  usually  occurs  after  forty-five  years  of  age.  The  tendency  to 
its  formation  is  in  some  cases  hereditary,  and  seems  to  be  associated 
with  gout  and  rheumatism.  Repeated  slight  traumation  is  an 
etiological  factor,  the  contraction  being  often  seen  in  those  who 
use  tools  which  press  upon  the  palm,  e.g.  carpenters  and  engravers. 
W.  Anderson  suggests  that  the  irritant  causing  the  contraction  is  of 
a  parasitic  nature,  and  others  consider  that  it  is  of  nervous  origin. 

Morbid  anatomy. — The  ring  and  little  fingers  are  especially 


)8 


MANUAL  OF   SURGERY 


CHAP. 


affected,  the  contraction  usually  beginning  in  the  former.  The 
tendons  are  not  in  any  way  affected  or  implicated,  the  contrac- 
tion being  limited  to  the  palmar 
fascia,  the  digital  slips  of  which  send 
lateral  prolongations  downwards  which 
are  attached  to  the  heads  of  the  meta- 
carpal bones  and  the  sides  of  the 
phalanges.  The  fascia  is  contracted 
and  hypertrophied,  and  definite  fibrous 
nodules  of  small  size  may  be  felt  in  it ; 
the  skin  becomes  dimpled,  puckered, 
thickened,  and  contracted,  and  blends 
with  the  fascia  beneath.  The  palmar 
fat  atrophies.  The  contracted  bands 
of  fascia  may  be  easily  felt,  and  are 
seen  as  rounded  cords  in  the  palm. 
As  the  contraction  is  in  progress  the 
movements  of  the  fingers  become  less 
free  and  the  patient  complains  of  in- 
FiG.  106.-A  dissection  Illustrating  the  crcasiug  stiffncss  ;  the  two  proximal 
contraction  of  the  pahnar  fascia  phalanges  are  flcxcd  towards  the  palm, 

and   Its  prolongations  in  Dupuy-     •■^  o  .  ... 

tren's  contraction  (Tubby,  after  but    the   distal  oue   remains   in   a   line 

with    the   second.      The   condition    in- 
creases slowly  but  certainly,  and  ultimately 
the  rigidly  flexed   fingers  very  much   im- 
pair the  usefulness  of  the  hand. 

Treatment. — In  the  very  early  stages 
the  patient  should  be  directed  to  counter- 
act the  tendency  to  contraction  by  manipu- 
lation and  massage  of  the  palm,  but  when 
the  flexion  is  established  operation  is  the 
only  means  of  effecting  a  cure.  The 
contracted  fascia  should  be  divided  by 
Adams's  method,  viz.  in  the  palm  on  each 
side  of  the  puckered  portion  of  skin,  and 
also  the  lateral  prolongations  passing  to 
the  sides  of  the  phalanges ;  care  being 
taken  not  to  wound  the  digital  vessels  and 
nerves.  Some  surgeons  prefer  to  divide 
the  bands  or  dissect  them  out  by  the 
open  method.  When  the  finger  has  been 
straightened  it  should  be  kept  in  position  by  a  palmar  splint 


Fig.  107. — Dupuytren's  contrac- 
tion  (Fergusson). 


xii  congp:nital  malformations  309 


CONGENITAL    CONTRACTION    OF    THE    FINGERS 

The  last  two  phalanges  are  sometimes  congenitally  flexed  owing 
to  contraction  of  the  digital  fascia.  The  condition  is  sometimes 
hereditary,  is  often  bilateral,  and  usually  affects  the  little  finger,  but 
may  also  occur  in  the  others.  The  treatment  is  similar  to  that  of 
Dupuytren's  contraction. 


CLUB-HAND 

Club-hand  is  a  rare  congenital  deformity;  it  is  usually  associated 
with  some  other  mal-dcvelopment,  or  with  absence  or  imperfect 
growth  of  the  bones  of  the  carpus  or  forearm ;  the  radius  is 
ofccn  absent,  and  in  this  case  the  ulnar  is  shortened  and  bowed 
with  the  concavity  towards  the  radial  side,  so  that  the  hand  is 
deflected  outwards. 

Treatment  consists  in  daily  massage  and  manipulation,  com- 
bined with  division  of  all  tendinous  structures  which  may  prevent 
the  proper  position  of  the  hand  being  attained.  In  cases  of  absent 
radius  it  has  been  suggested  to  split  the  ulna  longitudinally  and  thus 
form  two  bones. 


Congenital  Malformations  of  the  Lower  Urinary  Tract, 
OF  the  Genital  Organs,  and  of  the  Rectum  and  Anus 

Normal  development. — At  an  early  period  of  development 
the  hind-gut,  which  is  connected  anteriorly  with  the  allantois,  and 
posteriorly  by  the  post-anal  gut  with  the  neurenteric  canal  ends  as 
a  cul-de-sac,  but  at  about  the  eighth  week  the  gut  and  genito- 
urinary passage  open  on  the  surface  by  a  common  cloaca.  Subse- 
quently this  cloaca  is  subdivided,  and  the  communication  between 
the  allantois  and  the  hind-gut  is  obliterated  by  the  growth  of  a 
posterior  and  two  lateral  folds,  which  unite  to  form  the  perineum, 
and  hence  the  gut  remains  posteriorly,  and  the  urinary  and  genital 
passages  open  anteriorly,  the  opening  being  known  as  the  uro-genital 
sinus  {^fistulce.  betweot  rectum  and  bladder).  The  hind-gut  is  com- 
pleted by  the  proctodaeum,  which  is  a  depression  of  the  superficial 
structures ;  this  gradually  deepens  until  only  a  thin  membranous 
septum  separates  the  gut  from  the  surface,  the  opening  subsequently 
forming  by  absorption  of  this  membranous  partition  {imperforate 
alius). 


3IO  MANUAL   OF  SURGERY  chap. 

The  post-anal  gut  is  quite  a  temporary  structure,  and  is  early 
obliterated  {conge?iital  sacral  tumour). 

The  lower  end  of  the  allantois  and  the  Miillerian  ducts  open 
together  into  the  uro-genital  sinus,  but  become  separated  by  a 
septum  {vesico-vaginal  fistula).  The  upper  end  of  the  allantois  is 
obliterated,  and  remains  only  as  a  rounded  cord  (the  urachus), 
passing  upwards  to  the  umbilicus  from  the  bladder  {j>atent  urachus^ 
urachal  cysts). 

The  intermediate  portion  forms  the  bladder,  and  the  lower  part 
develops  into  the  urethra  of  the  female,  but  only  forms  the  prostatic 
and  membranous  portions  of  that  tube  in  the  male,  the  penile 
portion  being  developed  from  the  genital  folds,  as  will  be  presently 
seen. 

The  Miillerian  ducts  remain  separate  above  as  the  Fallopian 
tubes,  but  fuse  below  to  form  the  uterus  and  vagina  {uterus  bicornis, 
double  vagina) ;  in  the  male  these  tubes  are  represented  by  the 
uterus  masculinus.  Thus  at  the  uro-genital  sinus,  the  urethra,  and 
in  the  female  the  vagina  opens,  and  most  anteriorly  is  a  small 
prominence  (genital  eminence),  grooved  on  its  under  surface  by  the^, 
uro-genital  furrow,  and  flanked  on  each  side  by  a  small  fold  (the 
genital  fold).  In  the  male  the  genital  eminence  forms  the  penis, 
while  the  edges  of  the  genital  furrow  unite  to  form  the  penile 
urethra  and  corpus  spongiosum,  the  union  of  its  margins  taking 
place  from  behind  forwards  {hypospadias) ;  the  genital  folds  unite  in 
the  middle  line  to  form  the  scrotum  {cleft  scrotum).  In  the  female 
the  clitoris  is  developed  from  the  genital  eminence,  while  the  sides 
of  the  genital  furrow  form  the  nymph £e,  and  the  genital  folds 
enlarge  and  give  rise  to  the  labia  majora  {adherent  labia).  The 
hymen  appears  at  about  the  fifth  month  as  a  fold  of  mucous  mem- 
brane. On  each  side  of  the  female  urethra  two  small  orifices  of 
Skene's  tubes  open — these  are  the  lower  ends  of  the  Wolttian  ducts, 
which  in  the  male  develop  into  the  vasa  deferentia  and  vesiculae 
seminales. 

NARROW  MEATUS IMPERFORATE  URETHRA 

The  average  circumference  of  the  meatus  in  the  male  is  about 
25  mm.,  but  it  may  be  much  larger,  or  so  small  as  to  cause  actual 
obstruction  to  the  flow  of  urine,  coupled  with  painful  micturition 
and  signs  of  vesical  irritation.  K  persistent  gleet  is  sometimes 
traceable  to  the  narrowness  of  the  meatus.  The  meatus  is  usually 
quite  small  in  cases  of  hypospadias.     The  defect  is  easily  remedied 


XII  HYPOSPADIAS 


311 


by  passing  a  blunt-pointed  knife  into  the  urethra,  and  cutting  the 
floor  for  a  sufficient  distance,  the  cut  surfaces  being  kept  apart  for 
a  few  days  by  a  small  strip  of  oiled  lint. 

Occasionally  the  urethra  is  imperforate,  and  in  such  cases  there 
may  be  no  opening  for  the  escape  of  urine  and  consequent  secondary 
changes  in  the  bladder  or  kidneys,  or  there  may  be  an  abnormal 
opening  into  the  rectum  or  perineum.  If  the  occlusion  is  due  to  a 
septum  across  the  urethra,  this  must  be  broken  down,  but  if  the 
urethra  is  absent,  a  plastic  operation,  similar  to  that  for  hypospadias, 
must  be  performed. 


EPISPADIAS 

It  sometimes  happens  that  the  penis  is  twisted,  so  that  the 
urethra  appears  to  occupy  the  dorsal  surface,  and  if  this  is  deficient 
the  condition  is  known  as  epispadias.  Complete  epispadias  is  the 
usual  form,  and  is  associated  with  imperfect  development  of  the 
pelvic  girdle  and  extroversion  of  the  bladder.  The  penis  is  stunted 
and  rudimentary,  being  often  only  represented  by  an  imperfect 
glans ;  the  urethra  opens  at  its  root  close  to  the  pubes.  For  this 
condition  there  is  no  remedy.  Incomplete  epispadias  may  some- 
times be  benefited  by  a  plastic  operation  similar  to  that  practised 
for  hypospadias. 


HYPOSPADIAS 

If  the  edges  of  the  genital  furrow  fail  to  unite,  the  urethra  is 
deficient,  and  opens  on  the  under  surface  of  the  penis.  The  extent 
of  this  malformation  varies,  and  three  grades  of  hypospadias  are 
recognised. 

Varieties. — Hypospadias  of  the  glans  penis  is  a  common 
condition ;  the  floor  of  the  urethra  is  deficient,  and  on  the  under 
surface  of  the  glans  is  a  distinct  furrow.  The  prepuce  is  also 
deficient  below,  and  surrounds  the  glans  above  and  laterally  like 
a  cowl.  This  degree  needs  no  treatment,  but  if  the  meatus  is 
very  small  it  should  be  incised. 

Hypospadias  of  the  penis. — The  meatus  opens  on  the  floor 
somewhere  between  the  glans  and  the  scrotum,  a  groove  on  the  under 
surface  in  front  of  the  opening  indicating  the  genital  furrow.  In 
front  the  corpus  spongiosum  is  represented  by  a  dense  fibrous  cord, 
which  curves  the  stunted  penis  towards  the  scrotum,  the  curvature 


312 


MANUAL  OF   SURGERY 


CHAP. 


Fig.  io8. — Peno-scrotal  hypospadias 
a,  urethral  orifice  (Follin). 


being  especially  marked  during  erection.  If  the  meatus  is  far  back 
considerable  inconvenience  may  result,  and  during  connection  the 
semen  may  not  enter  the  vagina. 

This  defect  may  be  remedied  by 
operation. 

Complete  hypospadias  (H.  peri- 
nealis). — In  this  condition  the  urethra 
opens  on  the  perineum.  The  scrotum  is 
cleft,  the  testes  are  often  undescended, 
the  penis  is  curved,  short,  stunted,  and 
resembles  an  enlarged  clitoris,  so  that 
on  superficial  examination  the  parts  re- 
semble the  female  genitals.  The  patient 
has  to  micturate  like  a  woman,  in  the 
sitting  position,  and  even  if  coitus  can 
be  performed  the  semen  does  not  enter 
the  vagina. 

Hypospadias  in  women  is  very  rare ; 
the  urethra  opens  into  the  vagina. 
Operation  for  hypospadias.  —  It  is  advisable  to  operate 
when  the  patient  is  about  ten  or 
twelve  years  old,  for  he  will  then  be 
able  to  understand  the  necessity  for 
observing  the  directions  given  him, 
and  the  penis  is  sufficiently  developed 
to  offer  a  reasonable  chance  of  suc- 
cess. These  operations  frequently 
fail  owing  to  sloughing  or  inflamma- 
tion due  to  the  contact  of  the  urine, 
or  they  may  be  only  partially  suc- 
cessful. It  is  first  necessary  to 
divide  or  dissect  away  the  fibrous 
cord  which  keeps  the  penis  in  the 
curved  condition,  and  the  urethra 
may  be  formed  at  a  subsequent 
operation.  This  may  be  effected  by 
freshening  the  edges  of  the  furrow, 
and  uniting  them  over  a  catheter, 
but  in  the  great  majority  of  instances 
a  small  flap  has  to  be  raised  from  each  side,  and  these  are  united 
with  fine  silk  or  chromic  gut.  For  the  details  of  the  operation 
the  reader  is  referred  to  a  work  on  operative  surgery. 


Fig.  109. — Peno-scrotal  hypospadias. 
a,  urethral  orifice  (Follin). 


XII  ECTOPIA  VESICA  .       313 

PATENT    URACHUS 

If  the  upper  end  of  the  allantois  is  unobUterated  it  opens  at  the 
umbiUcus  as  a  urinary  fistula,  which  is  usually  quite  small  and 
may  undergo  spontaneous  cure.  The  condition  is  very  rare,  and, 
especially  if  the  opening  be  tolerably  large,  may  be  associated  with 
umbilical  hernia. 

Sometimes  the  allantois  is  shut  off  below,  so  that  there  is  no 
communication  with  the  bladder,  and  the  only  evidence  of  its  per- 
sistence is  a  narrow  and  perhaps  very  short  sinus  which  may  be  the 
seat  of  suppuration. 

If  spontaneous  cure  does  not  occur,  the  sinus  or  fistula  should 
be  dissected  out. 


IMPERFECT    OBLITERATION    OF    THE    URACHUS    WITH    CYSTIC 
DILATATION URACHAL    OR    ALLANTOIC    CYSTS 

The  upper  part  of  the  allantois  may  be  normally  obliterated  at 
the  bladder  and  at  the  umbilicus,  but  not  so  as  regards  the  inter- 
mediate portion,  which  may  then  become  distended  into  a  cyst  or 
series  of  cysts.  This  condition  is  precisely  like  that  which  may 
occur  in  connection  with  the  processus  ad  testem. 

The  cysts  are  situated  between  the  abdominal  wall  and  the 
parietal  peritoneum.  The  cyst  wall  contains  muscular  fibres  with 
fibrous  tissue,  and  a  lining  of  epithelium.  The  contents  may  be 
clear,  and  serous  or  mucoid.      Such  cysts  may  suppurate. 

Treatment. — These  cysts  may  be  treated  by  excision  or  by  free 
incision  and  drainage.  The  latter  is  the  safer  and  more  judicious 
course,  since  the  peritoneal  cavity  is  not  opened,  as  would  almost 
certainly  be  the  case  if  any  attempt  were  made  to  remove  the  cyst 
by  dissection. 

ECTOPIA    VESICA 

Extroversion  of  the  bladder  is  due  to  failure  of  closure  of  the 
anterior  abdominal  wall  with  deficiency  of  the  anterior  wall  of  the 
bladder.  The  pubic  arch  is  undeveloped  and  epispadias  is 
associated ;  the  testes  are  usually  undescended  and  the  scrotum 
is  small.  The  posterior  wall  of  the  bladder  projects  as  a  red 
fungous  mass  in  which  the  orifices  of  the  ureters  can  be  plainly 
seen.  The  constant  dribbling  of  the  urine  renders  the  patient's 
life  miserable,  especially  as  puberty  advances  and  the  pubic  hair 


314  MANUAL   OF  SURGERY  chap. 

becomes  encrusted  with  phosphates  from  the  decomposing  urine. 
The  exposed  mucous  membrane  not  infrequently  ulcerates  and 
bleeds,  but  as  age  advances  it  becomes  harder  and  its  mucous 
character  less  marked.  This  deformity  is  much  more  common  in 
males  than  females. 

Operative  treatment  should  usually  be  undertaken  when  the 
child  is  about  five  years  old.  The  operations  are  tedious  and 
complicated,  and  not  infrequently  fail  completely  or  require  repeti- 
tion on  account  of  sloughing.  Trendelenburg  recommends  the 
restoration  of  the  pelvic  girdle  before  attempting  to  close  the  gap 
in  the  abdominal  wall,  and  for  this  purpose  exposes  the  sacro-iliac 
joints,  divides  the  posterior  ligaments,  and  then  forces  the  pubic 
arch  together  and  maintains  the  pelvis  in  this  position  by  a  properly 
applied  girdle.  This  procedure  tends  to  very  much  narrow  the 
cleft,  and  renders  the  subsequent  closure  by  flaps  a  less  severe  and 
more  certain  procedure. 


CLEFT    SCROTUM 

This  malformation  is  not  uncommon,  and  may  be  associated 
with  perineal  hypospadias.  The  fault  is  due  to  failure  of  union  of 
the  genital  folds.  Each  half  of  the  scrotum  contains  a  testicle  if 
they  have  descended.     No  treatment  is  needed. 


ADHERENT    LABIA 

If  the  genital  folds  unite  in  the  female,  the  labia  majora  are 
united  in  the  middle  line.  They  should  be  incised  or  divided  by 
the  cautery  along  the  raphe,  and  reunion  must  be  prevented  by  the 
interposition  of  a  piece  of  oiled  lint  during  healing. 


MALFORMATIONS    OF    THE    RECTUM    AND    ANUS 

From  the  general  account  given  on  p.  309  of  the  normal 
process  of  de\-elopment  the  explanation  of  the  malformations  of 
the  rectum  will  be  easily  understood. 

Varieties — Anal  stricture. — Sometimes  the  anal  orifice  is  so 
small  that  it  will  only  admit  a  fine  probe.  It  should  be  enlarged 
by  a  median  incision  passing  towards  the  coccyx  and  be  kept  open 
by  bougies. 

Imperforate    rectum   (Fig.    no). — This  is   the    condition  in 


XII  MALFORMATIONS  OF  THE  RECTUM  AND  ANUS   315 

which  the  rectum  and  proctodaeum  are  both  developed,  but  have 
failed  to  unite  owing  to  persistence  of  the  septum,  which  must 
be  broken  down. 

Imperforate  anus  (Fig.  in). — The  rectum  is  normally  de- 
veloped, but  the  proctodeum  is  absent. 

Absent  rectum  (Fig.  112). — The  proctodaeum  mayor  may  not 


Fig.  no. — Imperforate  rectum.      Fig.  hi. — Imperforate  anus.  Fig.  112.— Absent  rectum. 


be  developed,  but  the  rectum  is  either  quite  absent  or  ends  high 
up,  its  lower  part  being  merely  represented  by  a  fibrous  cord. 

Atresia  ani  vesiealis  (Fig.  113),  urethralis  (Fig.  114),  and 
vagrinalis  (Fig.  115). — If  the  folds  which  should  cut  off  the  bowel 
from  the  urinary  tract  in  front  and  should  form  the  perineum  are 
defective,  one  or  other  of  these  conditions  will  be  present  according 


Fig.  ii3._ 
Atresia  ani  vesiealis. 


Fig.  114. 
Atresia  ani  urethralis 


Fig.  115. 
Atresia  ani  vaginalis. 


to  the  sex  of  the  patient  and  the  length  of  the  rectum ;  the  longer 
the  rectum  the  more  likely  is  it  to  communicate  with  the  urethra, 
and  consequently  the  more  easily  can  it  be  reached  by  operation. 

Signs. — Whatever  form  of  malformation  is  present  the  signs 
of  obstruction  soon  become  manifest,  for  even  if  there  is  an  open- 
ing through  the  urethra  or  bladder,  it  is  insufficient  to  permit  of 
the  free  passage  of  meconium. 

In  cases  of  imperforate  anus  or  rectum  the  distended  bowel 
can  easily  be  made  out  as  it  bulges  into  the  perineum,  especially 
when  the  child  cries. 


3i6  MANUAL  OF  SURGERY  chap,  xii 

Treatment. — ^Vhen  the  rectum  is  absent  an  attempt  may  be 
made  to  reach  it  by  a  careful  dissection  through  the  perineum,  the 
coccyx  being  removed  if  necessary ;  the  fibrous  cord  extending 
from  the  lower  end  of  the  bowel  may  be  followed  up  to  it  if  it  can 
be  defined.  If  the  gut  is  found  it  should  be  drawn  down  and 
united  to  the  skin,  for  unless  this  be  done  stricture  is  almost 
certain  to  occur.  If  the  above  operation  fails,  inguinal  colotomy 
must  be  performed ;  this  operation  is  also  necessary  in  atresia  ani 
vesicalis  or  urethralis. 

Except  in  the  very  simplest  forms  of  mal-development  of  the 
lower  bowel  the  ultimate  prognosis  is  very  bad,  for  even  if  the  child 
survive  the  operation  he  almost  invariably  dies  in  a  few  months. 

CONGENITAL    SACRAL    TUMOUR 

When  the  rectum  opens  on  the  surface  by  the  formation  of 
the  proctodaeum,  the  post-anal  gut  which  commiunicates  with  the 
neurenteric  canal  should  become  obliterated.  Sometimes  remains 
of  it  persist  and  give  rise  to  a  dermoid  or  cystic  tumour  between 
the  bowel  and  sacrum.  Such  a  tumour  may  grow  rapidly  and 
attain  a  very  large  size  so  that  the  child  looks  a  mere  appendage  of 
it.  The  tumour  displaces  the  pelvic  contents  and  grows  down- 
wards between  the  thighs,  and  also  spreads  upwards  along  the 
sacrum. 

The  cystic  form  of  tumour  is  composed  of  numerous  epithelium- 
lined  cysts  containing  clear  or  mucoid  fluid  and  frequently  intra- 
cystic  growths.  Fatty  and  fibrous  tissue  is  often  a  marked  feature 
of  the  growth  j  cartilage,  bone,  and  gland-tissue  may  also  be  met 
with. 

These  tumours  should  if  possible  be  removed,  but  the  operation 
is  at  all  times  dangerous  in  consequence  of  the  attachments  and 
pelvic  prolongations  of  the  growth. 


INDEX 


Abdomen,  contusions  of  the,  ii.  330 

—  injuries  of  the,  ii.  330 

—  penetration  of  the,  ii.  332 
Abdominal  muscles,  injury  of  the,  ii.  331 

—  section,  iii.  394 

—  viscera,  diseases  of  the,  iii.  367 

injuries  of  the,  ii.  333 

Abducens    oculi,    laceration   of   the,    ii. 

258 
Abscess,  acute,  i.  38.     See  Suppuration 

diagnosis  of,  i.  45 

formation  of,  i.  41 

signs  of,  i.  44 

treatment  of,  i.  45 

—  chronic,  i.  46 

anatomy  of,  i.  47 

dangers  of,  i.  48 

diagnosis  of,  i.  49 

etiology  of,  1.  47 

signs  of,  i.  49 

treatment  of,  i.  49 

—  glandular,  i,  50 

—  pyaemic,  i.  217 

—  residual,  i.  48 

—  subcutaneous,  i.  50,  152 

—  tubercular,  i.  47,  152 
Abscesses,  modes  of  opening,  i.  46 
Acromegaly,  iii.  114 
Acromion,  fracture  of  the,  ii.  150 
Actinomycosis,  i.  139 
Acupressure,  ii.  81 
Acupuncture  for  aneurism,  iii.  48 
Acute  necrosis,  iii.  119 
Addison's  keloid,  ii.  34 

Adductor  muscles,  rupture  of  the,  ii.  175 
Adenoids  in  the  pharynx,  iii.  263 
Adenoma,  racemose,  i.  248  ;  iii.  677 

—  tubular,  i.  249  ;   iii.  677 
Adenomata,  the,  i.  248 

VOL.  I 


Aerial  fistula,  ii.  291 
Agalactia,  iii.  669 
Air  in  the  veins,  ii.  63 

—  sinuses,  diseases  of  the,  iii.  260 
Albuminoid  degeneration,  i.  4 
Albuminuria,  iii.  497 

Alcoholic  coma,  ii.  249 
Alibert's  keloid,  ii.  33 
Allantoic  cysts,  i.  313 
Alopecia  syphilitica,  i.  185 
Alveolar  abscess,  iii.  314 

—  sarcoma,  i.  234 
Ammusat's  colotomy,  iii.  433 
Amputation,  circular,  ii.  208 

—  flap,  ii.  209 

—  for  frost-bite,  ii.  54 

—  for  gunshot  injury,  ii.  43 

—  modified  circular,  ii.  209 

—  oval,  ii.  209 

—  primary,  ii.  207 

—  racquet,  ii.  209 

—  secondary,  ii.  207^ 

—  stumps,  ii.  212.     See  Stumps 

—  transfixion,  ii.  209 
Amputations,  general  principles,  ii.  207 

—  methods  employed,  ii.  208 

—  mode  of  performing,  ii.  210 

—  special,  ii.  214 

of  the  arm,  ii.  218 

of  the  elbow,  ii.  217 

of  the  fingers,  ii.  214 

of  the  foot,  ii.  221 

of  the  forearm,  ii.  217 

of  the  forequarter,  ii.  220 

of  the  hip,  ii.  228 

of  the  knee,  ii.  226 

of  the  leg,  ii.  224 

of  the  penis,  iii.  603 

— -  —  of  the  shoulder,  ii.  219 


3i8 


MANUAL  OF  SURGERY 


Amputations,  special,  of  the  thigh,  ii.  226 

of  the  toes,  ii.  221 

of  the  wrist,  ii.  216 

Anaemia,  i.  10 
Anatomical  wart,  i.  153 
Aneurism,  iii.  24 

—  anatomy  of,  iii.  25 

—  arterio-venous,  ii.  61 

—  by  anastomosis,  iii.  3 

—  causes  of  iii.  24 

—  circumscribed  traumatic,  ii.  60 

—  cirsoid,  iii.  3 

—  consecutive,  iii.  26 

—  contents  of  the  sac  of,  iii.  28 

—  diagnosis  of,  iii.  32 

—  dissecting,  iii.  27 

—  fusiform,  iii.  26 

—  pressure  effects  of,  iii.  29 

—  prognosis  of,  iii.  33 

—  rupture  of,  iii.  33 

—  sacculated,  iii.  27 

—  signs  of,  iii.  31 

—  spontaneous  cure  of,  iii.  34 

—  suppuration  of,  iii.  35 

—  termination  of,  iii.  33 

—  traumatic,  ii.  58 

—  treatment  of,  iii.  37 

acupuncture,  iii.  48 

amputation,  iii.  49 

Anel's  operation,  iii.  38 

Antyllus's  operation,  iii.  44 

Brasdor's  operation,  iii.  43 

coagulating  injections,  iii.  48 

compression,  iii.  44 

distal  ligature,  iii.  43 

excision  of  the  sac,  iii.  44 

galvano-puncture,  iii.  47 

general  means,  iii.  37 

Hunter's  operation,  iii.  39 

Moore's  operation,  iii.  48 

proximal  hgature,  iii.  38 

Wardrop's  operation,  iii.  43 

—  varicose,  ii.  62 

—  weeping,  iii.  33 
Aneurismal  varix,  ii.  61 
Aneurisms,  special,  iii.  49 

—  of  the  abdominal  aorta,  iii.  51 
— -  of  the  axillary,  iii.  54 

—  of  the  brachial,  iii.  55 

—  of  the  carotids,  iii.  52 

—  of  the  common  femoral,  iii.  55 

—  of  the  deep  femoral,  iii.  56^ 

—  of  the  external  iliac,  iii.  55 

—  of  the  gluteal,  iii.  56 

—  of  the  innominate,  iii.  51 

—  of  the  intracranial  vessels,  iii.  53 


Anetirisms  of  the  intraorbital  vessels,  iii. 

53 

—  of  the  popliteal,  iii.  56 

—  of  the  radial,  iii.  55 

—  of  the  sciatic,  iii.  56 

—  of  the  subclavian,  iii.  53 

—  of  the  superficial  femoral,  iii.  56 

—  of  the  thoracic  aorta,  iii.  49 

—  of  the  tibials,  iii.  57 

—  of  the  ulnar,  iii.  55 
Angina  Ludovici,  i.  130 
Angiomata,  i.  245  ;  iii.  3 
Ankle,  dislocations  at  the,  ii.  203 

—  excision  of  the,  iii.  196 

—  fractures  of  the,  ii.  189 

—  sprained,  ii.  175 
Ankylosis,  iii.  185 

—  false,  iii.   186 
Annulus  migrans,  iii,  342 
Anthrax,  i.  112 

—  bacillus  of,  i.  113 
Antiseptic  surgery,  ii.  i 

—  drainage  tubes,  ii.  4 

—  dressings,  ii.  4 

—  instruments,  ii.  4 

—  ligatures,  ii.  4 

—  materials,  ii.  3 

—  ointments,  ii.  3 

—  solutions,  ii.  3 

—  sponges,  ii.  3 

—  sutures,  ii.  4 
Antiseptics,  ii.  3 
Anti-streptococcus  serurn,  i.  215 
in  cellulitis,  i.  129   ' 

in  emphysematous  gangrene,  i.  122 

in  er}-sipelas,  i.  126 

Anti-toxines,  i.  92 

—  in  erysipelas,  i.  126 

—  in  glanders,  i.  221 

—  in  rabies,  i.  134 

—  in  tetanus,  i.  138 


in  tubercle,  i.  i;i 


318 


Antrum,  hydrops  of  the,  iii. 

—  opening  the,  iii.  318 

—  suppuration  in  the,  iii.  317 

—  tumours  of  the,  iii.  318 
Anus,  artificial,  iii.  436 

—  congenital  stricture  of  the,  i.  314 

—  development  of  the,  i.  309 

—  diseases  of  the,  iii.  470 

—  fissure  of  the,  iii.  476 

—  fistula  of  the,  iii.  473 

—  imperforate,  i.  315 

—  malformations  of  the,  i. 

—  prolapse  of  the,  iii.  477 

—  priiritus  of  the,  iii.  471 


3M 


INDEX 


319 


Aorta,  aneurism  of  the  abdominal,  iii.  57 

—  aneurism  of  the  thoracic,  iii.  49 

—  ligature  of  the  abdominal,  iii.  81 
Aphthae,  iii.  330 

Apoplexy,  diagnosis  of,  ii.  248 
Appendicitis,  iii,  389 

—  relapsing,  iii.  393 

Appendi.\,  inflammation  of  the,  iii.  389 

—  removal  of  the,  iii.  393 

Aqueous  humour,  haemorrhage  into  the, 

ii.  304 
Arteries,  anatomy  of,  iii.  17 

—  calcification  of,  i.  79  ;  iii.  17 

—  contusion  of,  ii.  56 

—  diseases  of,  iii.  17 

—  fatty  degeneration  of,  iii.  17 

—  incised  wounds  of,  ii.  58 

—  inflammation  of,   iii.    18.       See 

Arteritis 

—  injuries  of,  ii.  56 

—  ligature  of,  iii.  58.     See  Ligature 

—  penetration  of,  ii.  57 

—  rupture  of,  ii.  56 
Arterio-venous  aneurism,  ii.  61 
Arteritis,  acute,  iii.  18 

—  chronic,  iii.  19 

—  spreading,  iii.  20 

—  syphilitic,  iii.  20 
Arthralgia,  syphilitic,  iii.  170 
Arthrectomy,  iii.  191 

Arthritis,  acute  suppurative,  iii.  151 

—  deformans,  iii.  174 

—  gouty,  iii.  173 

—  rheumatoid,  iii.  174 
- —  tubercular,  iii.  155 

of  the  elbow,  iii.  169 

of  the  hip,  iii.  163 

of  the  knee,  iii.  168 

of  the  sacro-iliac  joint,  iii.  162 

operations  for,  iii.  i6i 

prognosis  in,  iii.   158 

signs  of,  iii.  158 

treatment  of,  iii.  159 

Arthrotomy,  iii.  190 
Artificial  anus,  iii.  436 
Asthenic  fever,  i.  31 
Astragalo-scaphoid  capsule,  i.  299 
Astragalus,  dislocations  of  the,  ii.  205 

—  fracture  of  the,  ii.  191 
Atheroma,  iii.  21 
Atheromatous  cyst,  i.  262 
Atresia  ani,  i.  315 
Atrophy,  i.  7 

—  of  bone,  iii,  105 

—  of  the  breast,  iii,  671 

—  of  the  deltoid,  ii.  146 


Atrophy  of  the  muscles,  iii.  208 

—  of  the  testicle,  iii.  612 

Auditory  nerve,  laceration  of  the,  ii.  258 
A.xillary  artery,  aneurism  of  the,  iii.  54 
ligature  of  the,  iii,  74 

Bacilli,  i,  89 

Bacillus  anthracis,  i,  113 

—  coli  communis,  i.  41 

—  Ducrey's,  i.  208 

—  malignant  oedema,  i.  120 

—  mallei,  i.  219 

—  pyocyaneus,  i.  43 

—  tetani,  i.  136 

—  tuberculosis,  i.  145 
Bacteria,  i,  88 

—  classification  of  the,  i.  89 

—  physical  characters  of  the,  i.  88 

—  products  of  the,  i.  92 

—  relation  to  living  body,  i.  94 

—  structure  of  the,  i.  88 
Bacteriolog}',  i.  87 
Baker's  cysts,  iii.  149 
Balanitis,  iii.  599     . 
Balano-posthitis,  iii.  599 
Bandl's  ring,  ii.  355 
Bandy-legs,  i.  303 
Barbadoes  leg,  iii.  100 

Bartholin,  abscess  of  gland  of,  iii.  648 

Bassini's  operation,  iii.  462 

Bed-sores,  i.  jj 

Bell's  paralysis,  iii.  200 

Bladder,  anatomy  of  the,  iii.  536 

—  aspiration  of  the,  iii.  504 

—  catarrh  of  the,  iii.  540 

—  dilatation  of  the,  iii.  536 

—  diseases  of  the,  iii.  536 

—  disinfection  of  the,  ii.  6 

—  drainage  of  the,  iii.  504 

—  examination  of  the,  iii.  552 

—  extroversion  of  the,  i.  313 

—  foreign  bodies  in  the,  ii.  348 

—  hernia  of  the,  iii.  441 

—  hypertrophy  of  the,  iii.  536 

—  inflammation  of  the,  iii.  538 

—  irritability  of  the,  iii.  501 

—  malignant  disease  of  the,  iii.  546 

—  rupture  of  the,  ii.  348 

—  sacculation  of  the,  iii,  537 

—  stone  in  the,  iii.  547 

diagnosis  of,  iii.  553 

effects  of,  iii.  550 

signs  of,  iii.  551 

treatment  of,  iii.  553 

with  enlarged  prostate,  iii.  568 

—  tubercle  of  the,  iii.  541 


MANUAL   OF   SURGERY 


Bladder,  tumours  of  the,  iii.  542 
Blastomycetes,  i.  88 
Blood-vessels,  diseases  of  the,  iii.  i 

—  injuries  of  the,  ii.  56 

—  syphilis  of  the,  L  188  ;  iii.  20 
Boils,  i.  109 

Bone,  abscess  of,  iii.  127 

—  acute  necrosis  of,  iii.  119 

—  anatomy  of,  iii.  104 
— -  atrophy  of,  iii.  105 

—  caries  of,  iii.  123.      See  Caries 

—  cysts  of,  iii.  144 

—  diseases  of,  iii.  104 

—  expansion  of,  iii.  122 

—  hypertroph}'  of,  iii.  105 

—  intiammation  of,  iii.  117 

—  necrosis  of,  iii.  133.     See  Necrosis 

—  syphihs  of,  i.  188  ;  iii.  138 

—  tumours  of,  iii.  138 
Bones,  bending  of  the,  ii.  115 

—  contusion  of  the,  ii.  89 

•« —  gunshot  injuries  of  the,  ii.  39 

—  injuries  of  the,  ii.  89 
Bow  legs,  i.  303 

Brachial  artery,  aneurism  of  the,  iii.  55 
ligature  of  the,  iii.  77 

—  plexus,  stretching  the,  iii.  206 
Brain,  abscess  of  the,  iii.  225 

—  compression  of  the,  ii.  252 

—  concussion  of  the,  ii.  249 

—  contusion  of  the,  ii.  254 

—  diagnosis  of  injuries  to  the,  ii.  232 

—  diseases  of  the,  iii.  223 

—  haemorrhage  into  the,  ii.  247 

—  hernia  of  the,  ii.  258 

—  laceration  of  the,  ii.  254 

—  tumours  of  the,  iii.  235 

Breast,  abscess  of  the,  acute,  iii.  672 
of  the,  chronic,  iii.  674 

—  absence  of  the,  iii.  669 

—  adenoma  of  the,  iii.  677 

—  anatomy  of  the,  iii.  668 

—  atrophy  of  the,  iii.  671 

—  cancer  of  the,  iii.  681 

—  cysts  of  the,  iii.  692 

—  diseases  of  the,  iii.  668 

—  functional  anomalies  of  the,  iii.  669 

—  hydrocele  of  the,  iii.  694 

—  hypertrophy  of  the,  iii.  671 

—  inflammation  of  the,  acute,  iii.  672 
of  the,  chronic,  iii.  675 

—  neuralgia  of  the,  iii.  670 

—  removal  of  the,  iii.  688 

—  sarcoma  of  the,  iii.  68 1 

—  supernumerary,  iii.  669 

—  sj'philis  of  the,  iii.  676 


Breast,  tubercle  of  the,  iii.  676 

—  tumours  of  the,  iii.  677 
Bronchiectasis,  surgical  treatment  of,  iii. 

304 
Bronchocele,  iii.  309 
Bronchus,  foreign  body  in  a,  iii.  294 
Bubo,  i.  210 

—  treatment  of,  i.  212 
Bubon  d'embl^e,  i.  210 
Bubonocele,  iii.  457 
Bullets,  ii.  35 
Bunion,  iii.  221 
Burns,  ii.  45 

—  by  corrosives,  ii.  53 

—  complications  of,  ii.  47 

—  degrees  of,  ii.  45 

—  eftects  of,  ii.  46 

—  pathology  of,  ii.  48 

—  prognosis  of,  ii.  49 

—  treatment  of,  ii.  49 
Bursas,  diseases  of,  iii.  219 

—  false,  iii.  221 

—  inflammation  of,  iii.  219 
Bursitis,  acute,  iii.  219 

—  chronic,  iii.  220 

—  syphilitic,  iii.  222 

—  tubercular,  iii.  222 
Butcher's  wart,  i.  153 

Cachexia  strumipriva.  iii.  307 
Caesarean  section,  iii.  654 
Calcareous  infiltration,  i.  6 
Calcification  of  arteries,  iii.  17 

—  in  atheroma,  iii.  22 
Calculus  in  the  bladder,  iii.  547 

—  in  the  kidney,  iii.  521 

—  in  the  prostate,  iii.  575 

—  in  the  ureter,  iii.  527 

—  in  the  urethra,  ii.  343 

—  urinaiy,  carbonate  of  lime,  iii.  549 
causes  of,  iii.  521 

composition  of,  iii.  548 

—  —  cystine,  iii.  549 

general  structure  of,  iii.  550 

mixed,  iii.  549 

oxalate  of  lime,  iii.  548 

phosphatic,  iii.  549 

spontaneous  fracture  of,  iii.  551 

urate  of  ammonia,  iii.  548 

mic  acid,  iii.  548 

xanthine,  iii.  549 

Callus,  ii.  loi 

Calot's  treatment  for  spinal  caries,  iii.  249 

Cancer,  i.  250.     See  Carcinoma 

—  bodies,  i.  225,  251 
Cancrum  oris,  i.  115 


INDEX 


321 


Carbolic  acid,  ii.  3 
Carbuncle,  i.  109 

—  facial,  i.  112 
Carcinoma,  colloid,  i.  252 

—  duct,  i.  254  ;   iii.  687 

—  encephaloid,  i.  254 

—  ovariotomy  in  cases  of,  i.  253 ;  iii.  688 

—  rodent,  i.  257 

—  scirrhus,  i.  253 

—  thyroid,  i.  255 

—  villous,  i.  254  ;  iii.  687 
Carcinomata,  the,  i.  250 

—  degeneration  of,  i.  252 

—  secondary  deposits  of,  i.  251 

—  structure  of,  i.  250 

—  treatment  of,  i.  252 

—  varieties  of,  i.  252 
Garden's  amputation,  ii.  227 
Caries,  iii.  123 

—  central,  iii.  127 

—  of  the  ribs,  iii.  305 

—  of  the  spine,  iii.  241 

—  of  the  sternum,  iii.  305 

Carotid  arteries,  aneurism  of  the,  iii.  52 

—  ligature  of  the  common,  iii.  65 

of  the  external,  iii.  68 

-of  the  internal,  iii.  69 

Carpal  bones,  dislocation  of  the,  ii.  173 

fracture  of  the,  ii.  161 

Carr's  splint,  ii.  159 

Cartilage,  fibrillation  of,  iii.  175 

—  ulceration  of,  iii.  152 
Caruncle,  vascular,  iii.  594 
Castration,  iii.  637 

—  for  enlarged  prostate,  iii.  571 
Cataract,  concussion,  ii.  305 

—  traumatic,  ii.  309 
Catarrhal  inflammation,  i.  36 
Catheter  fever,  iii.  508 

Catheters,  mode  of  cleansing,  iii.  570 
Caustics,  burns  by,  ii.  53 
Celiotomy,  iii.  394 
Cellulitis,  i.  129 

—  of  the  neck,  i.  130 

—  of  the  orbit,  i.  130 

—  of  the  pelvis,  i.  131 

—  of  the  scalp,  i.  130 
Cellulo-cutaneous  er)sipelas,  i.  122 
Cephalhaematoma,  ii.  243 
Cerebral  abscess,  iii.  225 

—  contusion,  ii.  254 

—  embolism,  ii.  249 

—  haemorrhage,  ii.  247 

—  irritation,  ii.  256 

—  localisation,  ii.  233 

—  membranes,  diseases  of  the,  iii.  223 


Cerebral  topography,  ii.  236 

—  ventricles,  aspiration  of  the,  iii.  234 
Chancre,  extra-genital,  i.  171 

—  Hunterian,  i.  171 

—  mixed,  i.  169 

—  soft,  i.  208 

—  syphilitic,  i.  171 

—  urethral,  iii.  578 
Chancroid,  i.  208 
Charcot's  arthropathy,  iii.  179 
Cheeks,  disease  of  the,  iii.  329 
Chemiotaxis,  i.  21,  99 

Chest,  contusions  of  the,  ii.  319 

—  injuries  of  the,  ii.  319 

—  wall,  tumours  of  the,  iii.  306 

—  wounds  of  the,  ii.  323 
Chilblains,  ii.  55 
Chimney-sweep's  cancer,  iii.  606 
Cholecystectomy,  iii.  375 
Cholecystenterostomy,  iii.  375 
Cholecystotomy,  iii.  373 
Cholelithotrity,  iii.  374 
Chondromata,  the,  i.  241  ;  iii.  139 
Chondrosarcoma,  i.  235 
Chopart's  amputation,  ii.  222 
Choroid,  rupture  of  the,  ii.  306 

—  haemorrhage  from  the,  ii.  304 
Circulatory  disturbances,  i.  9 
Circumcision,  iii.  597 

Cirsoid  aneurism,  iii.  3 

Clavicle,  dislocations  of  the,  ii.  162 

—  fractures  of  the,  ii.  147 
Cleft  cheek,  i.  282 

—  lower  lip,  i.  282 

—  palate,  i.  282 

—  scrotum,  i.  314 
Cloacae,  iii.  135 

Club-foot,  i.  285.      See  Talipes 

—  hand,  i.  309 
Coagulation  necrosis,  i.  41 
Coccidia,  i.  225 
Coccydynia,  ii.  343 

Coccyx,  fracture  of  the,  ii.  343 
Cold,  local  effects  of,  ii.  53 
Colectomy,  iii.  423 
Coley's  fluid,  i.  253 
Collapse,  ii.  19.     See  Shock 
Colles's  fascia,  ii.  345 

—  fracture,  ii.  158 

—  law,  i.  200 
Colloid  cancer,  i.  252 

—  degeneration,  i.  6 
Colotomy,  inguinal,  .iii.  432 

—  lumbar,  iii.  433 
Complicated  fracture,  ii.  112 
Compound  fracture,  ii.  108 


322 


MANUAL  OF  SURGERY 


Compression,  cerebral,  ii.  252 

—  of  the  spinal  cord,  ii.  281 
Concussion,  cerebral,  ii.  249 

—  spinal,  ii.  266 
Condylomata,  syphilitic,  i.  179 
Congenital  dislocations,  ii.  128 
at  the  hip,  ii.  198 

—  sacral  tumour,  i.  316 

—  syphilis,  i.  200 

—  talipes,  i.  285 

—  tumours,  i.  258 
Congestion,  venous,  i.  to 
Conical  stump,  ii.  213 
Conjunctiva,  injuries  of  the,  ii.  299 
Contused  wounds,  ii.  18 

sutures  for,  ii.  13 

Contusion,  ii.  15 

—  cerebral,  ii.  254 

—  of  bones,  ii.  89 

—  of  joints,  ii.  117 

Coracoid  process,  fractures  of  the,  ii.  150 

Corn,  i.  247 

Cornea,  abcess  of  the,  ii.  303 

—  influence  of  escharotics  on  the,  ii.  300 

—  injuries  of  the,  ii.  299 

—  method  of  examining  the,  ii.  299 

—  penetration  of  the,  ii.  299 

—  ulcer  of  the,  ii.  303 
Corona  veneris,  i.  179 

Coronoid  process,  fracture  of  the,  ii.  160 
Corrosives,  burns  from,  ii.  53 

—  in  the  eye,  ii.  300 

—  in  the  oesophagus,  ii.  294 

Costal  cartilages,  fracture  of  the,  ii.  322 
Cracked  lip,  iii.  329 

—  nipple,  iii.  695 
Crania  bifida,  i.  275 

Cranial  ner\-es,  laceration  of  the,  ii.  257 

Craniectomy,  iii.  233 

Cranio-cerebral  topography,  ii.  236 

Craniotabes,  i.  203 

Crepitus,  ii.  93 

Cretinism,  iii.  307 

Cricoid  cartilage,  fracture  of  the,  ii.  293 

Croft's  splints,  ii.  188 

Cniral  canal,  anatomy  of  the,  iii.  462 

Crutch-palsy,  ii.  146 

Cut  throat,  ii.  289 

Cutaneous  erysipelas,  i.  122 

Cylindroma,  i.  234 

Cystic  epithehoma,  iii.  323 

—  hygroma,  iii.  99 
Cysticercus  cellulosas,  iii.  212 
Cystitis,  acute,  iii.  538 

—  chronic,  iii.  540 

—  gonorrhoeal,  i.  167 


Cystitis,  tubercular,  iii.  541 
Cystocele,  iii.  441 
Cystotomy,  perineal,  iii.  503 

—  suprapubic,  iii.  557 
dangers  of,  iii.  559 

—  —  in  women,  iii.  559 
Cysts,  i.  260 

—  allantoic,  i.  313 

—  compound,  i.  260 

—  dermoid,  i.  258 

—  extravasation,  i.  264 

—  exudation,  i.  263 

—  implantation,  i.  264 

—  in  joint  disease,  iii.  182 

—  Morrant  Baker's,  iii.  149 

—  origin  of,  i.  262 

—  parasitic,  i.  264 

—  proliferous,  i.  261 

—  retention,  i.  262 

—  sebaceous,  i.  262 

—  urachal,  i.  313 

—  varieties  of,  i.  262 

Dactylitis,  tubercular,  iii.  129 
Deformities,  i.  265 

—  of  the  head  and  neck,  i.  275 

—  of  the  limbs,  i.  285 

—  of  the  spine,  i.  265 

—  rachitic,  iii.  107 
Degeneration,  albuminoid,  i.  4 

—  calcareous,  i.  6 

—  colloid,  i.  6 

—  fatty,  i.  3 

—  mucoid,  i.  6 

—  of  muscles,  iii.  208 

—  of  nerves,  ii.  130 

—  reaction  of,  ii.  131 
Degenerations,  the,  i.  i 
Delirium,  traumatic,  ii.  24 

—  tremens,  ii.  24 

Deltoid,  bruising  of  the,  ii.  146 
Dentigerous  cyst,  iii.  326 
Dermoid  tumours,  i.  258 

ovarian,  i.  259  ;  iii.  660 

palatine,  iii.  335 

scrotal,  iii.  635 

sequestration,  i.  258 

sublingual,  iii.  333 

testicular,  iii.  635 

tubulo-,  i.  259 

Diabetic  coma,  ii.  249 

—  gangrene,  i.  84 

—  ulcer,  i.  67 
Diapedesis,  i.  17 

Diaphragm,  rupture  of  the,  ii.  331 
Diaphragmatic  hernia,  iii.  469 


INDEX 


323 


Diphtheria  of  wounds,  i.  119 
Diplococcus  gonorrhoece,  i,  156 

—  pneumoniLt',  i.  41 
Dislocations,  ii.  119 

—  complicated,  ii.  123 

—  compound,  ii.  124 

—  congenital,  ii.  128 

—  pathological,  ii.  127 

—  primary,  ii.   121 

—  secondary,  ii.  122 

—  spontaneous,  ii.  127 

—  subastragaloid,  ii.  205 

—  traumatic,  ii.  120 

anatomy  of,  ii.  120 

causes  of,  ii.  120 

prognosis  of,  ii.  122 

reduction  of,  ii.  122 

signs  of,  ii.  121 

—  unreduced,  ii.  125 
Dislocations,  special — 

—  of  the  astragalus,  ii.  205 

—  of  the  carpal  bones,  ii.  173 

—  of  the  clavicle,  ii.  162 

—  of  the  elbow,  ii.  169 

—  of  the  femur,  ii.  191 

—  of  the  foot,  ii.  203 

—  of  the  humerus,  ii.  164 

—  of  the  jaw,  ii.  287 

—  of  the  metacarpal  bones,  ii. 

—  of  the  metatarsal  bones,  ii. 

—  of  the  patella,  ii.  199 

—  of  the  phalanges,  ii.  173 

—  of  the  radius,  forwards,  ii, 

—  of  the  ribs,  ii.  322 

—  of  the  scapula,  ii.  163 

—  of  the  spine,  ii.  272 

—  of  the  tarsal  bones,  ii.  205 

—  of  the  tendons,  ii.  141 

—  of  the  thumb,  ii.  173 

—  of  the  tibia,  ii.  200 

—  of  the  wrist,  ii.  172 
Dog,  rabies  in  the,  i.  133 

Dorsalis  pedis  artery,  ligature  of  the,  iii. 

91 

Dressings,  antiseptic,  ii.  4 

Dubreuil's   amputation   at  the   wrist,    ii. 

217 
Ducrey's  bacillus,  i.  208 
Duct  cancer,  i.  254  ;  iii.  687 

—  cyst,  iii.  693 

—  papilloma,  iii.  693 
Duodenal  ulcer,  ii,  48 
Duodenostomy,  iii.  383 
Dupuytren's  contraction,  i.  307 

Dura  mater,   haemorrhage  beneath   the, 
ii.  247 


173 
206 


171 


Ear,  cerumen  in  the,  iii.  273 

—  diseases  of  the,  iii.  272 

—  foreign  bodies  in  the,  iii.  272 

—  granulations  in  the,  iii.  283 

—  hrematoma  of  the,  iii.  272 

—  injuries  of  the,  iii.  272 

—  polypus  in  the,  iii.  283 
Eburnation  of  bone,  iii.  176 
Ectopia  vesicas,  i.  313 

Elbow,  dislocations  at  the,  ii,  169 

—  e.\cision  of  the,  iii.  197 

—  fractures  at  the,  ii.  154 

—  tubercular  disease  of  the,  iii.  169 
Elephantiasis  arabum,  iii.  99 
Elephantoid  fever,  iii.  loi 
Embolism,  arterial,  iii.  10 

—  cerebral,  ii.  249 

—  fat,  ii.  94 

—  venous,  iii.  10 
Embryonic  inclusion,  i.  223 
Emphysema,  surgical,  ii.  326 
Emphysematous  gangrene,  i.  120 
Empyema  of  the  antrum,  iii.  317 

—  of  the  gall-bladder,  iii.  373 

—  operations  for,  iii.  302 

—  septic,  ii.  327 
Encephalocele,  i.  275 

Encysted  hasmatocele  of  the  cord,  iii.  642 
testis,  iii.  632 

—  hydrocele  of  the  cord,  iii.  641 

of  the  epididymis,  iii.  628 

of  the  testis,  iii.  628 

Endarteritis,  iii.  19 

—  deformans,  iii.  21 

—  proliferans,  iii.  20 

—  syphilitic,  iii.  20 
Endoscopy,  iii.  579 
Enophthalmos,  traumatic,  ii.  298 
Enterectomy,  iii.  423 
Enterocele,  iii.  440 
Enteroliths,  iii.  419 
Enterorrhaphy,  iii.  424 
Enterotomy,  iii.  432 

—  linear,  iii.  431 

Epididymis,  abscess  of  the,  iii.  616 

—  cysts  of  the,  iii.  628 

—  hydrocele  of  the,  iii.  628 

—  inflammation  of  the,  iii.  613 

—  tubercle  of  the,  iii.  619 
Epididymitis,  acute,  iii.  613 

—  chronic,  iii.  615 

—  gonorrhceal,  i.  167 
Epilepsy,  Jacksonian,  iii.  230 
Epileptic  coma,  ii.  249 
Epileptiform  neuralgia,  iii.  202 
Epiphyses,  separation  of  the,  ii.  114 


324 


MANUAL  OF   SURGERY 


190 

i8q 


See  Syphi- 


Epiphyses,  separation,  of  the  femur,  ii. 
182 

of  the  humerus,  ii.  155 

of  the  olecranon,  ii.   160 

of  the  radius,  ii.  160 

of  the  tibia  (lower),  ii. 

of  the  tibia  (upper),  ii. 

Epiphysitis,  iii.  132 
Epiplocele,  iii.  440 
Epispadias,  i.  311 
Epistaxis,  iii.  258 
Epithelial  odontorae,  iii.  323 
Epithelioma,  columnar,  i.  256 

—  of  scars,  ii.  33 

—  squamous,  i.  255 
Epithehomata,  the,  i.  255 
Epulis,  iii.  325 

Equinia,  i.  219.     See  Glanders 
Ergot  gangrene,  i.  84 
Eruptions,  syphilitic,  i.  177. 

lides 
Erj'sipelas,  i.  122 

—  anti-toxin,  i.  126 

—  causes  of,  i.  124 

—  cellular,  i.  129 

—  cellulo-cutaneous,  i.   127 

—  cutaneous,  i.  122 

—  organisms  in,  i.   122 

—  phlegmonous,  i.  127 
Excision,  of  the  eye-ball,  ii.  317 

—  of  the  ankle,  iii.  196 

—  of  the  condyle  of  the  jaw,  iii.  328 

—  of  the  elbow,  iii.  197 

—  of  the  hip,  iii.  192 

—  of  the  joints,  iii.  191 

—  of  the  knee,  iii.  194 

—  of  the  shoulder,  iii.  196 

—  of  the  wrist,  iii.  198 
Exostosis,  i.  242.     See  Osteoma 

—  subungual,  i.  242 
Extravasation  cysts,  i.  264 

—  of  urine,  ii.  346 
Exudate,  inflammatory,  i.  18 
E\^e,  excision  of  the,  ii.  317 

—  foreign  bodies  within  the,  ii.  311 

—  injuries  of  the,  ii.  297 
Eye-ball.      See  Globe 

Eye-lids,  foreign  bodies  beneath  the,  ii. 
301 

—  wounds  of  the,  ii.  298 
Eyes,  syphiUs  of  the,  i.  189 

Face,  development  of  the,  i.  278 

—  malformations  of  the,  i.  278 
- —  wounds  of  the,  ii.  283 

Facial  arter}-,  hgature  of  the,  iii.  71 


Facial  carbuncle,  i.  112 

—  erysipelas,  i.  124,  125 

—  nerve,  laceration  of  the,  ii.  258 
operation  on  the,  iii.  206 

paralysis  of  the,  iii.  200,  283 

Faecal  calculoids,  iii.  390 

—  fistula,  iii.  436 

—  impaction,  iii.  421 

Fallopian  tubes,  diseases  of  the,  iii.  655 

hydrops  of  the,  iii.  655 

inflammation  of  the,  iii.  655 

pregnancy  in  the,  iii.  656 

suppuration  in  the,  iii.  655 

False  passages  in  the  iirethra,  iii.  585 

False-joint,  ii.  105 

Farcy,  i.  219.      See  Glanders 

Fascia,  palmar,  contraction  of  the,  i.  307 

Fasciotomy,  i.  299 

Fat  embolism,  ii.  94 

Fatty  degeneration,  i.  3 

—  infiltration,  i.  3 

—  metamorphosis,  i.  3 

—  tumour,  i.  237 
Fehleisen's  streptococcus,  i.  122 
Femoral  artery,  aneurism  of  the,  iii.  55 

ligature  of  the  common,  iii.  85 

in  Hunter's  canal,  iii.  87 

in  Scarpa's  triangle,  iii.  85 

—  hernia,      iii.      462.        See      Herniae, 
Special 

Femur,  dislocations  of  the,  ii.  191 

anterior  oblique,  ii.  195 

causes  of,  ii.  192 

congenital,  ii.  198 

dorsal,  ii.  192 

everted  dorsal,  ii.  195 

perineal,  ii.  195 

pubic,  ii.  196 

supraspinous,  ii.  195 

—  —  thyroid,  ii.  195 

unreduced,  ii.  197 

varieties  of,  ii.  192 

—  fractures  of  the,  ii.  176 

extra-capsular,  ii.  178 

great  trochanter,  ii.  179 

intra-capsular,  ii.  176 

lower  end,  ii.  181 

shaft,  ii.  179 

—  separation  of  the  lower  epiphysis,  ii. 
182 

Ferments,  i.  87 

Fever,  aseptic  traumatic,  ii.  23 

—  asthenic,  i.  31 

—  elephantoid,  iii.  loi 

—  production  of,  i.  27 

—  prognosis  in,  i.  29 


INDEX 


325 


Fever,  sthenic,  i.  31 

—  symptoms  of,  i.  28 

—  syphilitic,  i.  173 

—  urethral,  iii.  508 
Fibroid,  recurrent,  i.  235 
Fibromata,  the,  i.  239 

Fibrous  union  after  fracture,  ii.  105 

of  the  olecranon,  ii.  160 

of  the  patella,  ii.  183 

Fibula,  fractures  of  the,  ii.  187 

Fifth  cranial  nerve,  laceration  of  the,  ii 

258 
Filaria  sanguinis  hominis,  iii.  99 
Fingers,   congenital  contraction  of   the, 
i.  309 

—  supernumerary,  i.  307 

—  webbed,  i.  307 
Fissure  of  the  anus,  iii.  476 
Fistula,  i.  54 

—  aerial,  ii.  291 

—  faecal,  iii.  436 

—  in  ano,  iii.  473 

—  parotid,  ii.  284 

—  recto-urethral,  iii.  494 

—  recto- vaginal,  iii.  648 

—  recto- vesical,  iii.  494 

—  vesico- vaginal,  iii.  648 
Flat-foot,  i.  295 

Fleischmann's  bursa,  cyst  of,  iii.  333 
Floating  kidney,  iii.  513 

—  spleen,  iii.  376 

Foot,  conservative  surger}'  of  the,  ii.  224 

—  dislocations  of  the,  ii.  203 

—  flat,  i.  295 

—  Madura,  i.  141 

—  wounds  of  the,  ii.  175 
Forci-pressure,  ii.  81 
Fore-arm,  fractures  of  the,  ii.  156 
Foreign  bodies  in  the  bladder,  ii.  348 
in  the  bronchi,  iii.  294 

in  the  eye,  ii.  311 

in  the  intestines,  ii.  340  ;  iii.  419 

in  the  larynx,  iii.  293 

in  the  lids,  ii.  301 

in  the  meatus  auditorius,  iii.  272 

in  the  nose,  iii.  257 

in  the  oesophagus,  ii.  295 

in  the  rectum,  ii.  351 

in  the  stomach,  ii.  340 

in  the  trachea,  iii.  294 

in  the  urethra,  ii.  343 

in  the  vagina,  ii.  354 

Fourth  cranial  nerve,  laceration  of  the, 

ii.  258 
Fractures,  ii.  89 

—  causes  of,  ii.  90 


Fractures,  comminuted,  iL  90 

—  complete,  ii.  89 

—  complicated,  ii.   112 

—  complications  after,  ii.  94 

—  compound,  ii.  108 

amputation  for,  ii.  no 

primary,  ii.  108 

secondary,  ii.  109 

treatment  of,  ii.  109 

union  of,  ii.  103 

—  delayed  union  of,  ii.  104 

—  diagnosis  of,  ii.  92 

—  essential  signs  of,  ii.  92 

—  false-joint  after,  ii.  105 

—  fibrous  union  of,  ii.  105 

—  greenstick,  ii.  115 

—  impacted,  ii.  90 

—  imperfect  repair  of,  ii.  103 

—  implicating  an  artery,  ii.  113 
a  joint,  ii.  113 

a  nerve,  ii.  113 

—  multiple,  ii.  90 

—  non-essential  signs  of,  ii.  93 

—  non-union  of,  ii.  104 

—  partial,  ii.  89 

—  plaster  casing  for,  ii.  99 

—  prognosis  of,  ii.  96 

—  repair  of,  ii.  10 1 

—  resection  in,  ii.  107 

—  setting  of,  ii.  97 

—  simple,  ii.  89 

—  splints  for,  ii.  98 

—  spontaneous,  ii.  90 

—  starch-bandage  for,  ii.  99 

—  treatment  of,  ii.  96 

—  ununited,  ii.  103 

—  varieties  of,  ii.  89 

—  vicious  union  after,  ii.  107 

—  wiring  fragments  of,  ii.  100,  107 

—  with  dislocation,  ii.  123 
Fractures,  special — 

of  the  ankle,  ii.  189 

of  the  astragalus,  ii.  191 

of  the  carpal  bones,  ii.  161 

of  the  clavicle,  ii.  147 

of  the  coccy.x,  ii.  343 

of  the  costal  cartilages,  ii.  322 

of  the  cricoid  cartilage,  ii.  293 

of  the  femur,  ii.  176 

of  the  fibula,  ii.  187 

of  the  foot,  ii.  191 

of  the  fore-arm,  ii.  156 

of  the  humerus,  ii.  151 

of  the  hyoid  bone,  ii.  292 

of  the  jaw  dower),  ii.  286 

of  the  jaw  (upper),  ii.  285 


326 


MANUAL   OF  SURGERY 


Fractures,  special,  of  the  leg,  ii.  187 

of  the  malar  bone,  ii.  285 

of  the  metacarpus,  ii.  161 

of  the  metatarsus,  ii.  191 

—  —  of  the  nasal  bones,  ii.  284 

of  the  OS  calcis,  ii.  191 

of  the  patella,  ii.  182 

of  the  pelvis,  ii.  341 

of  the  phalanges,  ii.  162 

of  the  radius,  ii.  157 

of  the  ribs,  ii.  320 

of  the  sacrum,  ii.  343 

of  the  scapula,  ii.  149 

of  the  skull,  ii.  238 

of  the  spine,  ii.  272 

of  the  sternum,  ii.  322 

of  the  tarsal  bones,  ii.  191 

of  the  thyroid  cartilage,  ii.  292 

of  the  tibia,  ii.  187 

of  the  trachea,  ii.  293 

of  the  ulna,  ii.  160 

of  the  zygoma,  ii.  285 

Fragilitas  ossium,  ii.  90  ;  iii.  105 

Frost-bite,  ii.  53 

Fungus  of  actinomycosis,  i.  139 

—  of  mycetoma,  i.  141 
Furuncle,  i.  109 

—  treatment  of,  i.  11 1 

Galactocele,  iii.  693 

Galactorrhoea,  iii.  669 

Gall-bladder,  empyema  of  the,  iii.  373 

—  injuries  of  the,  ii.  337 

—  operations  on  the,  iii.  373 

—  surgery  of  the,  iii.  371 
Gall-stones,  composition  of,  iii.  371 

—  effects  of,  iii.  371 

—  impacted,  iii.  372 

—  in  the  intestine,  iii.  419 
Ganglion,  compound,  iii.  218 

—  simple,  iii  219 
Gangrene,  i.  70 

—  amputation  for,  i.  77 

—  arterial  disease  in,  i.  79 

—  causes  of,  i.  70 

—  constitutional,  i.  73 

—  diabetic,  i.  84 

—  direct,  i.  73 

—  dry,  i.  73,  74 

—  emphysematous,  i.  120 

—  ergot,  i.  84 

—  from  cold,  ii.  53 

—  from  fracture,  ii.  95 

—  from  frost-bite,  ii.  54 

—  hospital,  i.  116 

—  indirect,  L  73 


Gangrene,  inflammatory,  i.  73 

—  micro-organisms  causing,  i.  86 

—  moist,  i.  73,  74 

—  pressure,  i.  77 

—  prognosis  of,  i.  76 

—  Raynaud's,  i.  82 

—  senile,  i.  79 

—  separation  of  dead  part  in,  i.  75 

—  signs  of,  i.  73 

— •  spreading  traumatic,  i.  120 

—  symmetrical,  i.  82 

—  symptoms  of,  i.  75 

—  traumatic,  i.  120 

—  treatment  of,  i.  76 

—  varieties  of,  i.  73 
Gartner's  duct,  cysts  of,  iii.  648 
Gasserian  ganglion,   removal  of  the,  iii. 

206 
Gastro-enterostomy,  iii.  382 
Gastrostomy,  iii.  384 
Gastrotomy,  iii.  384 

Genito-urinary   organs,    development    of 
the,  i.  309 

malformation  of  the,  i.  309 

Genu  recurvatum,  i.  303 

—  valgum,  i.  299 

osteotomy  for,  i.  302 

pathological,  i.  300 

rachitic,  i.  299 

static,  i.  300 

—  varum,  i.  303 
Geographical  tongue,  iii.  342 

Giant  cells   in   absorption    of   bone,   iii. 
124 

in  granulation  tissue,  ii.  28 

in  myeloid  sarcoma,  i.  236 

in  tubercle,  i.  146 

Gingivitis,  iii.  325 
Glanders,  i.  219 

—  causes  of,  i.  219 

—  diagnosis  of,  i.  221 

—  prognosis  of,  i.  221 

—  symptoms  of,  i.  219 

—  treatment  of,  i.  221 
Glandular  abscess,  i.  50 
Gleet,  iii.  578 
Glioma,  i.  233 

Globe,  contusions  of  the,  ii.  303 

prognosis  of,  ii.  306 

treatment  of,  ii.  306 

—  foreign  bodies  within  the,  ii.  311 

—  haemorrhage  into  the,  ii.  304 

—  injuries  of  the,  ii.  303 

—  penetration  of  the,  ii.  308 

—  septic  matter  within  the,  ii.  309 
Glossitis,  acute  superficial,  iii.  341 


INDEX 


327 


Glossitis,  chronic  superficial,  iii.  342 

—  parenchymatous,  iii.  3 

—  suppurative,  iii.  341 

—  tubercular,  iii.  346 

—  ulcerative,  iii.  341 
Glosso-pharyngeai    nerve,    laceration 

the,    i.  258 
Gluteal  artery,  aneiirism  of  the,  iii.  56 

ligature  of  the,  iii.  83 

Glycosuria,  iii.  499 
Goitre,  iii.  309 

—  acute,  iii.  308 

—  exophthalmic,  iii.  310 

—  malignant,  iii.  311 
Gonococcus,  the,  i.  156 
Gonorrhoea,  i.  156 

—  complications  of,  i.  163 

—  incubation  of,  i.  157 

—  in  the  female,  i.  162 

—  in  the  male,  i.  157 

—  irrigation  in,  i.  161 

—  retention  of  urine  from,  i.  168 

—  treatment  of,  i.  159,  163 
Gonorrhoeal  cystitis,  i.  167 

—  epididymitis,  i.  167 

—  prostatitis,  i.  167 

—  rheumatism,  i.  164 

—  warts,  i.  167 
Gouty  arthritis,  iii,  173 

—  ulcers,  i.  68 
Granulation,  i.  23 

—  union  by,  ii.  31 
Greenstick  fracture,  ii,  115 
Gummata,  i.  175 

—  peri-synovial,  iii.  171 

—  subcutaneous,  i.  184 

—  \-isceral,  i,  190 
Gummatous  synovitis,  i.  187 

—  s}-philide,  i.  183 

Gums,  diseases  of  the,  iii.  325 
Gun-shot  injuries,  ii.  35 

dangers  of,  ii,  41 

direct,  ii.  35 

indirect,  ii.  35 

mode  of  infliction  of,  ii.  35 

nature  of,  ii.  37 

prognosis  of,  ii.  41 

symptoms  of,  ii.  40 

treatment  of,  ii.  42 

Gutter-fracture,  ii.  39 

Haematocele  of  the  cord,  iii.  642 

—  of  the  epidid\-mis,  iii.  632 

—  of  the  scrotum,  iii.  605 

—  of  the  testis,  iii.  632 

—  of  the  tunica  vaginalis,  iii.  630 


of 


Haematoma  of  the  ear,  iii.  272 

—  subdural,  iii    223 

—  vulvag,  ii.  353 
Hctmato-pericardium,  iii.  305 
Haematuria,  iii.  498 
Haemophilia,  iii.  i 

—  joint  disease  in,  iii.  2 
Haemorrhage,  ii.  65 

—  arterial,  ii.  66 

—  beneath  the  dura  mater,  ii.  247 

—  capillar}',  ii,  67 

—  cerebral,  ii.  247 

—  constitutional  effects  of,  ii.  67 

—  death  from,  ii.  87 

—  intermediary,  ii.  84 

—  in  abdominal  injury,  ii,  334 

—  in  head  injur}',  ii.  243 

—  into  the  eye-ball,  ii.  304 

—  into  the  spinal  canal,  ii.  276 

—  middle  meningeal,  ii.  243 

—  primar}-,  ii.  67 
treatment  of,  ii.  82 

—  reactionar}',  ii.  67 
treatment  of,  ii.  84 

—  secondar}',  ii.  84 

—  spontaneous  arrest  of,  ii.  68 

—  treatment  after,  ii.  82 

—  treatment  of,  ii.  75 

—  venous,  ii.  66 
Haemorrhoids,  iii.  479 

—  capillar}',  iii.  480 

—  causes  of,  iii.  479 

—  external,  iii.  480 
treatment  of,  iii.  480 

—  internal,  iii.  481 
treatment  of,  iii.  482 

—  morbid  anatomy  of,  iii.  479 
Haemostatics,  ii.  77 
Hcemothorax,  ii.  325 

Hair,  syphilis  of  the,  i.  185 
Hallux  dolorosus,  i.  305 

—  rigidus,  i.  305 

—  valgus,  i.  304 
Hamilton's  splint,  ii.   180 
Hammer-toe,  i.  306 
Hamstrings,  rupture  of  the,  ii.  175 
Hands,  conservative  siu-gery  of  the, 

216 

—  crushes  of  the,  ii.  144 

—  disinfection  of  the,  ii.  6 

—  needles  in  the,  ii.  144 
Hare-lip,  i.  278 

—  double,  i.  281 

—  single,  i.  279 

Head,  injuries  of  the,  ii,  230 
Heart,  injuries  of  the,  ii.  327 


328 


MANUAL  OF  SURGERY 


Heat,  physiolog}'  of,  i.  26 

Hectic,  i.  108 

Hepatic  abscess,  iii.  367 

—  colic,  iii.  371 

treatment  of,  iii.  373 

—  dysentery,  iii.  367 

Hernia  of  the  abdomen,  iii.  439 

—  acquired,  iii.  442 

—  congenital,  iii.  442,  458 

—  general  anatomy  of,  iii.  439 

—  general  patholog}^  of,  iii.  443 

—  incarcerated,  iii.  448 

—  inflamed,  iii.  449 

—  internal,  iii.  407 

—  irreducible,  iii.  446 

—  Littr^'s,  iii,  440 

—  radical  cure  of,  iii.  446 

—  reducible,  iii.  443 

—  reduction  en  masse,  iii.  456 
Hernia,  Richter's,  iii.  440 

—  strangulated,  iii.  450 

diagnosis  of,  iii.  452 

morbid  anatomy  of,  iii.  450 

operation  for,  iii.  453 

signs  of,  iii.  451 

treatment  of,  iii.  453 

—  of  the  brain,  ii.  258 

—  of  the  lung,  ii.  327 

—  of  the  testicle,  iii.  622 

—  special,  iii.  457 

—  diaphragmatic,  iii.  469 

—  femoral,  iii.  462 

anatomy  of,  iii.  462 

diagnosis  of,  iii.  463 

radical  cure  of,  iii.  464 

strangulated,  iii.  465 

treatment  of,  iii.  464 

—  inguinal,  iii.  457 

anatomy  of,  iii.  457 

congenital,  iii.  ^.58 

diagnosis  of,  iii.  459 

direct,  iii.  459 

infantile,  iii.  459 

interstitial,  iii.  459 

oblique,  iii.  458 

radical  cure  of,  iii.  461 

strangulated,  iii.  462 

treatment  of,  iii.  460 

—  lumbar,  iii.  467 

—  obturator,  iii.  468 

—  pelvic,  iii.  468 

—  sciatic,  iii.  468 

—  umbilical,  iii.  465 

—  ventral,  iii.  467 
Hernial  sac,  the,  iii.  439 
coverings  of,  iii.  442 


Hernial  sac,  hydrocele  of,  iii.  441 

Herniotomy,  iii.  453 

Herpes  progenitalis,  i.  211  ;   iii.  600 

Hey's  amputation,  ii.  221 

Hip,  amputation  at  the,  ii.  228 

—  arthrectomy  of  the,  iii.  192 

—  bruising  of  the,  ii.  176 

—  disease  of  the,  iii.  163 

—  dislocations  at  the,  ii.  191 

—  excision  of  the,  iii.  192 
Hodgkin's  disease,  iii.  loi 
Hospital  gangrene,  i.  116 
Horn,  cutaneous,  i.  247 
Housemaid's  knee,  iii.  219 
Humerus,  dislocations  of  the,  ii.  164 
compound,  ii.  169 

prognosis  of,  ii.  167 

reduction  of,  ii.  167 

signs  of,  ii.  165 

unreduced,  ii.  168 

varieties  of,  ii.  165 

—  fractures  of  the,  ii.  151 

great  tuberosity,  ii.  152 

lower  end,  iu  154 

neck,  ii.  151 

shaft,  ii.   153 

—  separation  of  the  epiphyses  of  the,  ii. 

155 
Hutchinson's  triad,  i.  205 
Hydatid  cysts  of  bone,  iii.  144 

of  the  liver,  iii.  369 

of  the  muscles,  iii.  212 

Hydrarthrosis,  iii.  149 

—  syphilitic,  iii.  171 

—  tubercular,  iii.  162 
Hydrocele,  en  bissac,  iii.  622 

—  encysted,  of  the  cord,  iii.  641 

of  the  epididymis,  iii.  628 

of  the  testis,  iii.  628 

—  of  the  breast,  iii.  694 

—  of  the  canal  of  Xuck,  iii.  646 

—  of  a  hernial  sac,  iii.  441 

—  of  the  ovary,  iii.  662 

—  of  the  tunica  vaginalis,  iii.  622 
acute,  iii.  623 

causes  of,  iii.  623 

congenital,  iii.  623 

course  of,  iii.  625 

diagnosis  of,  iii.  625 

infantile,  iii.  623 

morbid  anatomy  of,  iii.  623 

priman,-,  iii.  623 

secondary,  iii.  623 

signs  of,  iii.  624 

simple,  iii.  622 

treatment  of,  iii.  626 


INDEX 


329 


Hydrocephalus,  iii.  233 

—  drainage  for,  iii.  234 
Hydro-nephrosis,  iii.  515 
Hydrophobia,  i.  131.     See  Rabies 
Hydrops  antri,  iii.  318 
Hydro-salpinx,  iii.  655 
Hygroma,  cystic,  i.  246  ;  iii.  99 
Hyoid  bone,  fracture  of  the,  ii.  292 
Hyf>ercemia,  arterial,  i.  10 

—  venous,  i.  10 
Hyperostosis,  iii.  115 
Hypertrophy,  i.  8 

—  of  bone,  iii.  105 

—  of  the  breast,  iii.  671 

—  of  the  labia,  iii.  645 
Hyphomycetes,  the,  i.  88 
Hvpoglossal  ner\-e,  laceration  of  the,  iL 

'258 
Hypopyon  ulcer,  ii.  302 
Hyposp>adias,  i.  311 
Hysterectomy,  iii.  651 
Hysteria,  traumatic,  ii.  266 

Ichthyosis  linguae,  iii.  343 

Ileus  paralyticus,  iii.  421 

Iliac  artery,  aneurism  of  the  external,  iii. 

55 

ligature  of  the  common,  iii.  81 

of  the  external,  iii.  83 

of  the  internal,  iii.  82 

Immunity,  i.  96 

—  artificial,  i.  97 

—  chemistr)-  of,  i.  100 

—  natural,  i.  97 

—  phagocytosis  in,  i.  97 
Imperforate  anus,  i.  315 

—  rectum,  i.  314 

—  urethra,  i.  310 
Implantation  cysts,  i.  264 
Incarcerated  hernia,  iii.  448 
Incised  wounds,  ii.  17 
Incontinence  of  urine,  iii.  500 
Indolent  ulcer,  i.  65 

Infection,  immunity  against,  i.  96 

—  proneness  to,  i.  95 

—  refractor}'  to,  i.  95 
Infective  diseases,  i.  102 

causes  favouring  the,  i.  104 

general,  i.  213 

local,  i.  109 

prevention  of  the,  i.  105 

—  intiammation.  i.  15 

—  processes,  i.  95 

Inferior  dental  nerve,  operation  on  the, 

iii.  206 
Infiltration,  calcareous,  i.  6 


Infiltration,  fatty,  i.  3 
Inflamed  tumours,  i.  226 

—  ulcer,  i.  67 
Inflammation,  i.  11 

—  adhesive,  i.  15 

—  causes  of,  i.  13 

—  duration  of,  i.  15 

—  gangrene  from,  i.  70 

—  infective,  i.  15 

—  phlegmonous,  i.  15 

—  septic,  i.  14 

—  simple,  i.  14 

—  spreading,  i.  15 

—  varieties  of,  i.  14 

—  acute,  i.  15 

effects  of,  L  18 

pathology  of,  i.  20 

phenomena  of,  i.  15 

signs  of,  i.  24 

symptoms  of,  L  26 

termination  of,  i.  21 

treatment  of,  i.  30 

—  catarrhal,  i.  36 

—  chronic,  i.  33 

causes  of,  L  33 

results  of,  i.  34 

signs  of,  i.  35 

treatment  of,  i.  35 

laflammator}-  exudate,  i.  18 
Infra-orbital   nerse,    operation    on    the, 

iii.  205 
Ingrowing  toe-nail,  i.  305 
Inguinal  canal,  anatomy  of  the,  iii.  457 

—  hernia,  iii.  457,     See  Hemice,  Special 
Injuries,  ii.  15 

—  eflfects  of,  ii.  19 

—  gun-shot,  ii.  35.     See  Gun-shot 
Innominate  arter)',  aneurism  of  the,  iii.  51 
ligature  of  the,  iii.  64 

Insanity,  traumatic,  ii.  259 
Internad  hernia,  iii.  407 
Intestinal  approximation,  iii.  42 

end-to-end,  iii.  427 

end-to-side,  iii.  429 

side- to-side,  iii.  429 

—  obstruction,  iii.  398 

acute,  iii,  398 

causes  of,  iii.  402 

chronic,  iii.  401 

diagnosis  of,  iii.  402 

laparotomy  for,  iii.  404 

prognosis  of  iii.  403 

treatment  of,  iii.  403 

Intestine,  compression  of  the,  iii.  422 

—  foreign  bodies  in  the,  ii.  340  ;  iii.  419 

—  gangrene  of  the,  iii.  454 


33° 


MANUAL   OF   SURGERY 


Intestine,  injuries  of  the,  ii.  336 

—  operations  on  the,  iii.  423 

—  resection  of  the,  iii,  423 

—  short-circuiting  the,  iii.  429 

—  stricture  of  the,  iii.  415 

—  suturing  the,  iii.  425 
Intra-cranial  aneurism,  iii.  53 
Intra-orbital  aneurism,  iii.  53 
Intubation  of  the  larynx,  iii.  295 
Intussusception,  acute,  iii,  410 

—  chronic,  iii.  414 

—  of  the  dying,  iii.  412 
Iodides  in  syphihs,  i.  198 
lodism,  i.    198 

Iritis,  syphilitic,  i.  189 

Irrigation  of  operation  wounds,  ii.  7 

Irritable  ulcer,  i.  66 

Ischasmia,  i.  9 

Ischio-rectal  abscess,  iii.  472 

Jacksonian  epilepsy,  iii.  230 

Jaw,  lower,  dislocation  of  the,  ii,  287 

fracture  of  the,  ii.  286 

removal  of  the,  iii.  323 

subluxation  of  the,  ii.  289 

tumours  of  the,  iii,  322 

—  upper,  fracture  of  the,  ii.  285 

removal  of  the,  iii.  320 

tumours  of  the,  iii.  318 

Jaws,  alveolar  abscess  of  the,  iii,  314 

—  closure  of  the,  iii.  327 

—  diseases  of  the,  iii.  314 

—  necrosis  of  the,  iii.  315 

—  periostitis  of  the,  iii.  314 

—  tumours  of  the,  iii.  322 
Jejunostomy,  iii.  383 
Joints,  anatomy  of,  iii.  145 

—  ankylosis  of,  iii.  185 

—  arthrectomy  of,  iii.  191 

—  aspiration  of,  iii.  190 

—  contusion  of,  ii.  117 

—  diseases  of,  iii.  145 

—  dislocation  of,  ii,  119.   See  Dislocations 

—  excision  of,  iii.   191 

—  gun-shot  injuries  of,  ii.  39 

—  haemophilia  affecting,  iii.  2 

—  injuries  of,  ii.  117 

—  loose  bodies  in,  iii.  183 

—  neuralgia  of,  iii.  188 

—  operations  on,  iii.  190 

—  penetration  of,  ii.  118 

—  pseudo-ankylosis  of,  iii.  186 

—  sprains  of,  ii.  117 

• —  syphilis  of,  iii.  170 

—  syringomyelia  affecting,  iii.  240 
Jordan's,  Furneaux,  amputation,  ii.  228 


Keloid,  Addison's,  ii,  34 

—  Alibert's,  ii,  33 

—  scar,  ii.  33 

Keratitis,  interstitial,  i.  206 

—  punctata,  ii.  316 

—  vascular,  i,  206 

Kidney,  abscess  round  the,  iii.  518 

—  anatomy  of  the,  iii.  512 

—  calculus  in  the,  iii,  521" 

causes  of,  iii.  521 

diagnosis  of,  iii.  525 

effects  of,  iii.  522 

— ■  —  history  of,  iii.  523 

signs  of,  iii.  524 

treatment  of,  iii.  526 

varieties  of,liii.  522 

—  cysts  of  the,  iii.  529 

—  diseases  of  the,  iii.  512' 

—  enlargement  of  the,  iii.  514" 

—  floating,  iii.  513 

—  injuries  of  the,  ii.  338 

—  operations  on  the,  iii.  531 

—  surgical,  iii.  518 

—  tubercular,  iii.  520 

—  tumours  of  the,  iii.  528 

Knee,  amputation  through  the,  ii.  226 

—  arthrectomy  of  the,  iii.  194 

—  excision  of  the,  iii.  195 

—  sprains  of  the,  ii.  176 

—  white-swelling  of  the,  iii.  168 
Kobelt's  tubes,  iii.  659 

—  cysts  of,  iii.  662 

Kocher,  reduction  of  dislocated  humerus, 
ii.  167 

—  removal  of  the  tongue,  iii.  355 
Koch's  postulates,  i.  88 

Kraske's  operation  for  proctectomy,  iii. 

491 
Kyphosis,  i.  270 

Labia,  adherent,  i.  314 

—  C3sts  of  the,  iii.  648 

—  elephantiasis  of  the,  iii.  645 

—  hypertrophy  of  the,  iii.  645 

—  tumours  of  the,  iii.  646 
Lacerated  wounds,  ii.  18 
Laceration,  cerebral,  ii,  254 
Laminectomy,  iii.  255 

—  for  fractured  spine,  ii,  275 

—  results  of,  iii.  256 
Lar\'ngectomy,  iii.  300 
Laryngitis,  acute,  iii,  286 

—  chronic,  iii.  288 

—  membranous,  iii.  287 

—  syphilitic,  iii.  290 

—  tubercular,  iii,  289 


INDEX 


331 


Larynj^otomy,  lii.  299 

Larynx,  adenomata  of  the,  iii.  291 

—  cancer  of  the,  iii.  292 

—  cysts  of  the,  iii.  292 

—  diseases  of  the,  iii.  286 

—  excision  of  the,  iii.  300 

—  fibromata  of  the,  iii.  291 

—  foreign  bodies  in  the,  iii.  293 

—  intubation  of  the,  iii.  295 

—  oedema  of  the,  iii.  286 

—  papillomata  of  the,  iii.  291 
Lateral  anastomosis,  intestinal,  iii.  429 

—  sinus,  thrombosis  of  the,  iii.  228 

trephining  the,  iii.  230 

Leeches,  mode  of  applying,  ii.  306  note 
Leg,  fractures  of  the,  ii.  187 
Leiomyoma,  i.  245 

Lens,  dislocation  of  the,  ii.  305 
Leontiasis  ossea,  iii.  115 
Leptomeningitis,  cerebral,  iii.  224 

—  spinal,  iii.  237 

Leucoma  of  the  tongue,  iii.  343 

Leucoplakia,  iii.  343 

Ligature  of  arteries,  the,  iii.  58 

—  accidents  after,  iii.  64 

—  accidents  during,  iii.  62 

—  choice  of  a,  iii.  58 

—  fate  of  a,  iii.  59 

—  for  aneurism,  iii.  38 

dangers  of,  iii.  41 

effects  of,  iii.  41 

failure  of,  iii.  42 

seat  of,  iii.  38 

Ligature  of  special  arteries,  iii.  64 

—  of  the  abdominal  aorta,  iii,  81 

—  of  the  anterior  tibial,  iii.  90 

—  of  the  axillaiy,  iii.  74 

—  of  the  brachial,  iii.  77 

—  of  the  common  carotid,  iii.  65 

—  of  the  common  femoral,  iii.  85 

—  of  the  common  iliac,  iii.  81 

—  of  the  dorsalis  pedis,  iii.  91 

—  of  the  external  carotid,  iii.  68 

—  of  the  external  iliac,  iii.  83 

—  of  the  facial,  iii.  71 

—  of  the  gluteal,  iii.  83 

—  of  the  innominate,  iii.  64 

—  of  the  internal  carotid,  iii.  6g 

—  of  the  internal  iliac,  iii.  82 

—  of  the  lingual,  iii.  70 

—  of  the  occipital,  iii.  71 

—  of  the  popliteal,  iii.  88 

—  of  the  posterior  tibial,  iii.  88 

—  of  the  radial,  iii.  78 

—  of  the  subclavian,  iii.  72 

—  of  the  superficial  femoral,  iii.  85 


Ligature  of  the  temporal,  iii.  71 
■ —  of  the  ulnar,  iii.  79 

—  of  the  vertel)ral,  iii.  74 
Ligatures,  asei)tic,  ii.  4 
Linear  osteotom}',  iii.  118 

—  proctotomy,  iii.  488 

Lingual  artery,  ligature  of  the,  iii.  70 
Lipoma  nasi,  iii.  265 
Lipomata,  the,  i.  237 
Lips,  cracked,  iii.  329 

—  diseases  of  the,  iii.  329 

—  hypertrophy  of  the,  iii.  329 

— -  restoration  of  the  lower,  iii.  332 

—  tumours  of  the,  iii.  331 

—  ulceration  of  the,  iii.  329 
Lisfranc's  amputation,  ii.  221 
Lister's  amputation,  ii.  226 
Lithotomy,  lateral,  iii.  557 

—  median,  iii.  557 

—  supra-pubic,  iii.  557 
Lithotrity,  iii.  554 

—  in  children,  iii.  556 

—  in  women,  iii.  556 

—  perineal,  iii.  556 
Littr^'s  colotomy,  iii,  432 

—  hernia,  iii.  440 

Liver,  abscess  of  the,  iii.  367 

—  hydatids  of  the,  iii.  369 

—  injuries  of  the,  ii.  337 

—  surgery  of  the,  iii.  367 
Lock-jaw,  i.  136.     See  Tetanus 
Loose  bodies  in  joints,  iii.  183 
Lordosis,  i.  270 

Loreta's  operation,  iii.  382 
Lumbar  hernia,  iii.  467 
Lung,  collapse  of  the,  ii.  326 

—  contusion  of  the,  ii.  324 

—  foreign  bodies  in  the,  ii.  325 

—  hernia  of  the,  ii.  327 

—  injuries  of  the,  ii.  323 

—  operations  on  the,  iii.  304 

—  rupture  of  the,  ii.  324 

—  wounds  of  the,  ii.  324 
Lupus  erythematosus,  i.  154 

—  tubercular,  i.  153 
Lymphadenitis,  iii.  94 

—  tubercular,  iii.  95 
Lymphadenoma,  iii.  loi 
Lymphangiectasis,  iii.  98 
Lymphangioma,  i.  246  ;  iii,  98 

—  of  the  tongue,  iii.  347 
Lymphangitis,  iii.  93 

Lymphatic  glands,  inflammation  of  the, 
iii.  94 

syphilis  of  the,  i.  186 

tubercle  of  the,  iii.  95 


OJ 


MANUAL  OF   SURGERY 


Lymphatic   glands,   tumours  of  the,   iii. 

103 
Lymphatics,  diseases  of  the,  iii.  93 
Lymphoma,   i.  233  ;   iii.  loi 
Lymphorrhoea,  iii.  98 
Lympho-sarcoma,  i.  233  ;  iii.  loi 
Lymph-scrotum,  iii.  99 

Macroglossia,  iii.  347 

Macrophages,  i.  98 

Madura  foot,  i.  141 

Malar  bones,  fracture  of  the,  ii.  285 

Malignancy,  local,  i.  229 

—  general,  i.  229 

—  nature  of,  i.  229 

—  signs  of,  i.  230 

Malignant  oedema,  bacillus  of,  i.  120 

—  pustule,  i.  112 

—  tumours,  i.  229 

—  ulcers,  i.  68 
Mallein,  i.  221 
Marmorek's  antitoxin,  i.  126 
Marriage  of  syphilitics,  i.  192 
Mastitis,  acute,  iii.  672 

—  chronic,  iii.  675 
Mastodynia,  iii.  670 
Mastoid  abscess,  iii.  281 

—  chronic  inflammation  of  the,  iii.  282 

—  periostitis,  iii.  281 

Maunsell's  operation  for  enterorrhaphy, 

iii.  427 
Meatus  auditorius,  foreign  bodies  in  the, 
iii.  272 

inflammation  of  the,  iii.  274 

osteoma  of  the,  iii.  274 

Meckel's  diverticulum,  hernia  of,  iii.  440 
obstruction  by,  iii.  405 

—  ganglion,  removal  of,  iii.  205 
Melanotic  sarcoma,  i.  235 
Meningeal  haemorrhage,  ii.  243 

prognosis  of,  ii.  245 

signs  of,  ii.  244 

treatment  of,  ii.  246 

Meningocele,  cranial,  i,  275 

—  spinal,  i.  266 
Meningo-myelocele,  i.  266 
Mercurial  course,  duration  of  a,  i.  197 

—  fumigation,  i.  196 

—  injections,  i.  197 

—  inunction,  i.  195 

—  salivation,  i.  194 

Mercury  salts  as  antiseptics,  ii.  3 
Mesentery,  prolapse  of  the,  iii.  442 
Metacarpal  bones,  dislocation  of  the,  ii. 

173 
fracture  of  the,  ii.  161 


Metamorphosis,  i.  i 

Metatarsal  bones,   dislocation  of  the,  ii. 
206 

fractures  of  the,  ii.  191 

Meteorism,  iii.  399 
Microcephalic  idiocy,  iii.  232 
Micrococci,  the,  i.  89 

—  reproduction  of,  i.  89 
Micrococcus  tenuis,  i.  41 
Micro-organisms,   conditions  inimical  to 

the,  i.  91 

—  exclusion  from  wounds  of,  ii.  i 

—  in  fever,  i.  27 

—  in  gangrene,  i.  86 

—  in  syphilis,  i.  168 

—  life-history  of  the,  i.  90 

—  mode  of  action  of  the,  i.  94 

—  mutability  of  species  of,  i.  93 

—  non-pathogenic,  i.  89,  94 

—  pathogenic,  i.  89,  94 

—  reproduction  of  the,  i.  93 
Microphages,  i.  99 
Micturition,  disorders  of,  iii.  499 

—  frequent,  iii.  499 

—  painful,  iii.  505 
MoUities  ossium,  iii.  113 
MoUuscum  fibrosum,  i.  240 
Mortification,  i,  70.      See  Gangrene 
Morton's  fluid,  i.  268 

Motor  oculi  nerve,  laceration  of  the,  ii. 

258 
Moulds,  i.  88 
Mouth,  diseases  of  the  floor  of  the,  iii. 

329 

—  disinfection  of  the,  ii.  6 
Mucoid  degeneration,  i.  6 

Mucous  membranes,  inflammation  of,  i. 

36 
syphiUs  of,  i.  185 

—  surfaces,  disinfection  of,  ii.  6 

—  tubercles,  i.  179 
Mumps,  iii.  356 
Murphy's  button,  iii.  425 
Muscles,  atrophy  of,  iii.  208 

—  contusions  of,  ii.  138 

—  degeneration  of,  iii.  208 

—  diseases  of,  iii.  208 

—  gun-shot  injury  of,  ii.  39 

—  inflammation  of,  iii.  209 

—  injuries  of,  ii.  138 

in  the  lower  hmb,  ii.  175 

in  the  upper  limb,  ii.  144 

—  neuralgia  of,  iii.  208 

—  paralysis  of  the  eye,  ii.  305 

—  parasites  in,  iii.  212 

—  repair  of,  ii.  140 


INDEX 


333 


Muscles,  nipture  of,  ii.  139 
in  tetanus,  i.  137 

—  tumours  of,  iii.  211 

—  wounds  of,  ii.  139 
Musculo-spiral  paralysis,  ii.  146 
Mutability  of  species,  i.  93 
Myalgia,  iii.  208 
Mycetoma,  i.  141 

Myelitis,  iii.  236 
Myeloid  sarcoma   i.  235 
Myoniata,  i.  245 
Myosarcoma,  i.  235 
Myositis,  iii.  209 

—  ossificans,  iii.  210 

—  syphilitic,  iii.  210 
My.xoedema,  iii.  307 
Myxomata,  i.  240 

Naevo-lipoma,  i.  237  ;  iii.  5 
Naevus,  iii.  5 

—  arterial,  iii.  3 

—  capillary,  iii.  5 

—  lymphatic,  iii.  98 

—  treatment  of,  iii.  6 

—  venous,  iii.  5 

Nails,  syphilis  of  the,  i.  185 
Narcotic  coma,  ii.  249 
Nares,  plugging  the  posterior,  iii.  258 
Nasal  bones,  fracture  of  the,  ii.  284 

—  polypi,  iii.  265 

—  septum,  diseases  of  the.  iii.  259 
Naso-pharynx,  tumours  of  the,  iii.  269 
Nat i form  skull,  i.  204 

Necrosis,  iii.  133 

—  acute,  iii.  119 

—  central,  iii.  134 

—  dry,  iii.  137 

—  included,  iii.  134 

—  of  stumps,  ii.  214 

—  of  the  jaws,  iii.  314 

—  peripheral,  iii.  134 

—  quiet,  iii.  137 

—  treatment  of,  iii.  136 
Needles,  embedded,  ii.  144 
Ndaton's  line,  ii.  194 
Nephrectomy,  iii.  534 
Nephro-lithotomy,  iii.  532 
Nephrorrhaphy,  iii.  531 
Nephrotomy,  iii.  532 
Ner\e-grafting,  ii.  135 

—  stretching,  iii.  204 
Nerves,  anatomy  of,  ii.  129 

—  bulbous,  ii.  213 

—  compression  of,  ii.  136 

—  contusion  of,  ii.  136 

—  cranial,  laceration  of  the,  ii.  257 

VOL    I 


Nerves,  degeneration  of,  ii.  130 

—  diseases  of,  iii.  200 

—  gun-shot  injuries  of,  ii.  39 

—  inflammation  of,  ii.  137  ;   iii.  200 

—  injuries  of,  ii.  129 

in  dislocation,  ii.  124 

in  fracture,  ii.  113 

—  operations  on,  iii.  204 

—  physiology  of,  ii.  130 

—  repair  of,  ii.   130 

—  section  of,  ii.   131 

—  spinal,  injury  of  the,  ii.  277 

—  suture  of,  ii.   133 

—  trophic  changes  after  injury  of,  ii.  132 

—  tumours  of,  iii.  207 

—  ulceration  after  injury  of,  i.  68 
Nervous  system,  syphilis  of  the,  i.  189 
Neuralgia,  iii.  202 

—  epileptiform,  iii.  202 
Neurasthenia,  ii.  266 
Neurectomy,  iii.  205 
Neuritis,  iii.  200 

—  traumatic,  ii.  137 
Neuromata,  i.  245  ;   iii.  207 
Neuro-mimesis,  iii.  188 
Neurotomy,  iii.  205 
Nipple,  cancer  of  the,  iii.  697 

—  cracked,  iii.  695 

—  diseases  of  the,  iii.  695 

—  eczema  of  the,  iii.  696 

—  Paget' s  disease  of  the,  iii.  696 

—  retracted,  iii.  695 

—  syphilis  of  the,  iii.  696 

—  ulcerated,  iii.  695 
Noma,  i.  115 

Non-union  of  fractures,  ii.  104 
Nose,  bleeding  from  the,  iii.  258 

—  diseases  of  the,  iii.  257 

—  foreign  bodies  in  the,  iii.  257 

—  syphilis  of  the,  iii.  259 

—  tumours  of  the,  iii.  265 
Nutrition,  i.  2 

Obturator  hernia,  iii.  468 

Occipital  artery,  ligature  of  the,  iii.  71 

Odontomata,  i.  244  ;   iii.  326 

—  composite,  i.  244 

—  compound  follicular,  i.  244 

—  epithelial,  i.  244  ;  iii.  323 

—  fibrous,  i.  244 

—  follicular,  i.  244  ;  iii.  326 
CEdema  laryngis,  iii.  286 
CEsophagectomy,  iii.  366 
CEsophagostomy,  iii.  366 
Q£sophagotomy,  iii.  366 
(Esophagus,  cancer  of  the,  iii.  363 

Z 


03' 


MANUAL  OF  SURGERY 


CEsophagus,  compression  of  the,  iii.  365 

—  dilatation  of  the,  iii.  360 

—  diseases  of  the,  iii.  360 

—  effects  of  caustics  on  the,  ii.  294 

—  foreign  bodies  in  the,  ii.  295 

—  inflammation  of  the,  iii.  362 

—  injuries  of  the,  ii.  293 

—  innocent  tumours  of  the,  iii.  366 

—  operations  on  the,  iii.  366 

—  rupture  of  the,  ii.  294 

—  sacculation  of  the,  iii.  361 
ffisophagus,  spasm  of  the,  iii.  365 

—  stricture  of  the,  iii.  363 
Olecranon,    epiphysis,   injury   of  the,    ii. 

160 

—  process,  fracture  of  the,  ii.    160 
Olfactory  nerve,  laceration  of  the,  ii.  257 
Onychia  maligna,  i.  305 

—  syphilitic,  i.  186 
Oophorectomy,  iii.  666 

—  for  cancer  of  the  breast,  iii.  688 
Oophoron,  cysts  of  the,  iii.  660 
Operations,  after-treatment  of,  ii.  11 

—  aseptic,  ii.  5 

Ophthalmia,  sympathetic,  ii.  314 
Optic  nerve,  laceration  of  the,  ii.  257 

—  neuritis,  in  syphilis,  i.  190 
Orbital  cellulitis,  i.  130 
Orchitis,  acute,  iii.  613 

—  chronic,  iii.  615 

—  syphilitic,  iii.  617 
Organisation,  i.  23,  24 

Os  calcis,  fracture  of  the,  ii.  191 
Osteitis,  chronic,  iii.   123 

—  deformans,  iii.  116 

—  rarefactive,  iii.  123 
Osteo-aneurism,  iii.  141 
Osteo-arthritis,  iii.   174 

Osteoma,  cancellous,  i.  243  ;  iii.  140 

—  ivory,  i.  242  ;   iii.  141 
Osteomalacia,  iii.  113 
Osteomyelitis,  iii.  129 

—  infective,  iii.  130 

—  tubercular,  iii.  129 
Osteo-sarcoma,  i.  235 
Osteotomy  for  genu  valgum,  i.  302 

—  linear,  iii.  118 
Otitis  media,  iii.  276 

complications  of,  iii.  280 

purulent,  iii.  278 

Ovarian  cysts,  iii.  659 

classification  of,  iii.  659 

complications  of,  iii.  662 

diagnosis  of,  iii.  664 

general  structure  of,  iii.  660 

origin  of,  iii.  659 


Ovarian  cysts,  treatment  of,  iii.  666 

—  dermoids,  iii.  660 

—  hydrocele,  iii.  662 

Ovaries,  cysts  of  the,  iii.  659.    See  Ovarian 
Cysts 

—  diseases  of  the,  iii.  659 

—  solid  tumours  of  the,  iii.  665 
Ovariotomy,  iii.  666 

—  for  cancer  of  the  breast,  iii.  688 
Oxygen  treatment  for  ulcers,  i.  63 
Ozoena,  iii.  262 

Pachymeningitis,  iii.  223 
Paget's  disease  of  the  nipple,  iii.  696 
Palate,  diseases  of  the,  iii.  334 
Palm,  suppuration  in  the,  ii.  142 

—  wounds  of  the,  ii.  142 

Palmar  arches,  wounds  of  the,  ii.  143 
Pancreas,  cyst  of  the,  iii.  377 

—  surgery  of  the,  iii.  377 
Panophthalmitis,  ii.  313 
Papillomata,  i.  246 
Paraphimosis,  iii.  598 
Parasites  in  muscle,  iii.  212 
Parasitic  cysts,  i.  264 

—  origin  of  tumours,  i.  225 
Parieto-occipital  fissure,  ii.  237 
Paronychia  tendinosa,  iii.  214 
Paroophoron,  cysts  of  the,  iii.  661 
Parotid  duct,  fistula  of  the,  ii.  284 

—  —  wounds  of  the,  ii.  284 
— •  tumours,  iii.  358 
Parotitis,  iii.  356 
Parovarian  cysts,  iii.  661 
Parrot's  bossing,  i.  203 

Pasteur's  treatment,  i.  134.      See  Rabies 
Patella,  dislocations  of  the,  ii.  199 

—  fracture  of  the,  ii.  182 

—  —  ununited,  ii.  187 

wiring,  ii.  184 

Patent  urachus,  i.  313 
Pathological  dislocation,  ii.  127 

Paul's   operation    for  enterorrhaphy,   iii. 

428 
Pectoralis  major,  rupture  of  the,  ii.  319 
Pelvic  cellulitis,  i.  131 

—  herniae,  iii.  468 

—  viscera,  injur}'  of  the,  ii.  341 
Pelvis,  fracture  of  the,  ii.  341 
Pemphigus,  syphilitic,  i.  202 
Penis,  amputation  of  the,  iii.  603 

—  cancer  of  the,  iii.  602 

—  diseases  of  the,  iii.  596 

—  gangrene  of  the,  iii.  600 

—  new  growths  of  the,  iii.  602 

—  removal  of  the,  iii.  604 


INDEX 


335 


Penis,  sloughing  of  the,  iii.  600 

Perforating  ulcer,  iii.  201 

Peri -arteritis,  iii.   19 

Pericardial    effusion,    operations  for,   iii. 

305 
Pericardium,  aspiration  of  the,  iii.  305 

—  incision  of  the,  iii.  305 

—  injuries  of  the,  ii.  327 
Perigastric  abscess,  iii.  381 
Perineal  abscess,  iii.  590 

—  dislocation,  ii.  195 

—  fistula,  iii.  591 
Perinephritic  abscess,  iii.  518 
Perineum,  ruptured,  ii.  353 
Perionychia,  syphilitic,  i.  202 
Periosteum,  separation  of  the,  ii.  89 
Periostitis,  acute,  iii.  118 

—  chronic,  iii.  121 

—  infective,  iii.  119 
Peri-splenic  abscess,  iii.  376 
Peritonism,  iii.  388 
Peritonitis,  iii.  385 

—  acute  septic,  iii.  387 

—  tubercular,  iii.  385 
Peri-typhlitis,  iii.  389 

Peroneal  artery,  ligature  of  the,  iii.  90 
Pes  planus,  i.  295 
Phagedaena,  sloughing,  i.  118 
Phagocytes,  i.  98 

—  fixed,  i.  99 
Phagocytosis,  i.  19,  97 
Phalanges,  dislocation  of  the,  ii.  173 

—  fracture  of  the,  ii.  162 
Pharyngitis,  acute,  iii.  263 

—  follicular,  iii.  261 
Pharyngocele,  iii.  361 
Pharynx,  adenoids  of  the,  iii.  263 

—  diseases  of  the,  iii.  261 
Phimosis,  acquired,  iii.  597 

—  congenital,  iii.  596 
Phlebitis,  iii.  10 

—  adhesive,  iii.  12 

—  causes  of,  iii.   10 

—  infective,  iii.  13 

—  morbid  anatomy  of,  iii.  11 

—  retrograde,  iii.  228 
Phosphorus  necrosis,  iii.  315 
Pied  tabetique,  iii.  201 

Piles,  iii.  479.      See  Hcemorrhoids 
PirogofFs  amputation,  ii.  223 
Plantar  fascia,  division  of  the,  i.  299 
Pleura,  fluid  in  the,  removal  of,  iii.  301 

—  injuries  of  the,  ii.  323 
Pleurisy,  traumatic,  ii.  327 
Plexiform  neuroma,  iii.  207 

—  sarcoma,  i.  234 


560 


Pneumonia,  traumatic,  ii.  327 
Pneumo-thorax,  ii.  326 
Polydactylism,  i.  307 
Polypus,  aural,  iii.  283 

—  nasal,  iii.  265 

—  naso-pharyngeal,  iii.  269 
Popliteal    artery,    aneurism    of    the,    iii 

56 
ligature  of  the,  iii.  88 

—  nerves,  exposure  of  the,  iii.  207 
Porro-Caesurean  operation,  iii.  655 
Pott's  disease  of  the  spine,  iii.  241 

—  fracture,  ii.  189 

—  puffy  tumour,  iii.  223 
Pregnancy,  tubal,  iii.  656 
Procidentia  recti,  iii.  477 
Proctectomy,  iii.  490 
Proctitis,  acute,  iii.  477 
Proctotomy,  iii.  488 
Prolapsus  ani,  iii.  477 
Prostate,  abscess  of  the,  iii, 

—  anatomy  of  the,  iii.  560 

—  calculi  in  the,  iii.  575 

—  cancer  of  the,  iii.  574 
— -  diseases  of  the,  iii.  560 

—  enlarged,  iii.  565 

calculus  complicating,  iii.  568 

castration  for,  iii.  571 

— ■  —  causes  of,  iii.  565 

complications  of,  iii.  567 

complications,    treatment    of    the, 

iii.  572 
diagnosis  of,  iii.  568 

—  —  morbid  anatomy  of,  iii.  565 

operations  for,  iii.  571 

retention  with,  iii.  572 

signs  of,  iii.  566 

treatment  of,  iii.  569 

— -  —  vasectomy  for,  iii.  572 

—  inflammation  of  the,  iii.  560 

— •  innocent  tumours  of  the,  iii.  573 

—  malignant  tumours  of  the,  iii.  574 
Prostatectomy,  iii.  571 
Prostatitis,  acute,  iii.  560 

—  chronic,  iii.  562 

—  gonorrhoeal,  i.  167 

—  tubercular,  iii.  563 
Prostatorrhcea,  iii.  563 
Protozoa  in  cancer,  i.  225 
Pruritus  ani,  iii.  471 

—  vulvae,  iii.  645 
Psammoma,  i.  246 
Psoas  abscess,  in,  253 

—  magnus,  rupture  of  the,  ii.  332 
Psoriasis  linguae,  iii.  343 
Pulmonary  abscess,  opening  a,  iii.  304 


MANUAL  OF  SURGERY 


Pulmonar}''  cavities,  opening,  iii.  304 

Punctured  wounds,  ii.  18 

Pus,  i.  43 

Pustule,  malignant,  i.  112 

Pyaemia,  i.  214,  216 

—  abscesses  in,  i.  217 

—  acute,  i.  216 

—  chronic,  i.  219 
Pyelo-nephritis,  iii.  518 
Pylorectomy,  iii.  382 
Pyloroplasty,  iii.  382 

Pylorus,  dilatation  of  the,  iii.  382 

—  obstruction  of  the,  iii.  378 
Pyogenic  organisms,  i.  40 

action  of,  i.  41 

influence  of,  i.  39 

Pyonephrosis,  iii.  515 
Pyopericardium,  operation  for,  iii.  305 
Pyosalpinx,  iii.  665 

Pyrogenic  substances,  i.  27 
Pyuria,  iii.  498 

Rabies,  i.  131 

—  causes  of,  i.  131 

—  diagnosis  of,  i.  133 

—  dumb,  i.  134 

—  in  the  dog,  i.  133 

—  incubation  of,  i.  132 

—  inoculation  against,  i.  134 

—  paralytic,  i.  134 

—  post-mortem  appearance^  of,  i.  134 

—  prognosis  of,  i.  134 

—  symptoms  of,  i.  132 

—  treatment  of,  i,  134 

Radial  artery,  aneurism  of  the,  iii.  55 

ligature  of  the,  iii.  78 

Radius,   dislocation  forwards  of  the,   ii. 
171 

—  fracture  of  the,  ii.  157 
Ranula,  iii.  333 

Ray  fungus,  the,  i.  139 
Raynaud's  disease,  i.  82 

—  gangrene,  i.  72 
Recto-urethral  fistula,  iii.  494 

—  vaginal  fistula,  iii.  648 

—  vesical  fistula,  iii.  494 
Rectum,  absent,  i.  315 

—  abscess  of  the,  iii.  472 

—  anatomy  of  the,  iii.  470 

—  cancer  of  the,  iii.  488 

—  compression  of  the,  iii.  492 

—  development  of  the,  i.  309 

—  diseases  of  the,  iii.  470 

—  disinfection  of  the,  ii.  6 

—  fistulas  with  the,  iii.  494,  648 

—  foreign  bodies  in  the,  ii.  351 


Rectum,  imperforate,  i.  314 

—  injuries  of  the,  ii.  351 

—  malformations  of  the,  i.  314 

—  procidentia  of  the,  iii.  477 

—  removal  of  the,  iii.  490 

—  stricture  of  the,  iii,  470 

fibrous,  iii.  485 

malignant,  iii.  488 

signs  of,  iii.  486 

syphilitic,  iii.  485 

treatment  of,  iii.  487,  488 

—  tumours  of  the,  iii.  492 

—  wounds  of  the,  ii.  352 
Reel-feet,  i.  291 

Re-fracture  for  vicious  union,  ii.  108 
Renal  colic,  iii.  523 

—  tumour,  diagnosis  of  a,  iii.  514 
Repair,  i.  23 

—  of  wounds,  ii.  26 
defective,  ii.  32 

Resection  for  ununited  fracture,  ii.  107 

—  for  vicious  union,  ii.  108 
Residual  abscess,  i.  48 
Resolution,  i.  22 

Retention  of  urine,  acute,  iii.  503 

chronic,  iii.  501 

effects  of,  iii.  506 

gonorrhceal,  i.  168 

Retina,  detachment  of  the,  ii.  305 
Retinal  haemorrhage,  ii.  304 
Retro-collis,  i.  276 
Retro-pharyngeal  abscess,  iii.  263 
Reverdin's  skin-grafting,  i.  63 
Rhabdomyoma,  i.  235,  245 
Rhagades,  i.  180 
Rhinitis,  atrophic,  iii.  262 

—  hypertrophic,  iii.  261 
Rheumatism,  syphilitic,  i.  174 
Rheumatoid  arthritis,  iii.  174 
Rhinoliths,  iii.  257 

Ribs,  caries  of  the,  iii.  305 

—  dislocation  of  the,  ii.  322 

—  fracture  of  the,  ii.  320 
Richter's  hernia,  iii.  440 
Rickets,  iii.  106 

—  foetal,  iii.  112 

—  infantile,  iii.  iii 

—  late,  iii.  106 

—  scurvy,  iii.  iii 
Rider's  bone,  iii.  210 
Rodent  ulcer,  i.  257 
Rouge's  operation,  iii.  268 
Rupia,  i.  182 

Rupture  of  the  perineum,  ii.  353 

—  of  the  urethra,  ii.  344 

—  of  the  uterus,  ii.  355 


INDEX 


337 


Sacro-iliac  joint,  tubercle  of  the,  iii.   162 
Sacrum,  fractures  of  the,  ii.  343 
Sahcyhc  acid,  an  antiseptic,  ii.  3 
iSahne  sokition,  intravenous  injection  of, 

ii.  87 
SaHvary  calculus,  iii.  358 

—  glands,  diseases  of  the,  iii.  356 

inflammation  of  the,  iii.  356 

tumours  of  the,  iii.  358 

Salivation,  mercurial,  i.  194 
Salpingitis,  iii.  655 

Sapritmia,  i.  106 
Sarcoma,  alveolar,  i.  234 

—  melanotic,  i.  235 

—  myeloid,  i.  235 

—  ple.xiform,  i.  234 

—  round-celled,  i.  233 

—  spindle-celled,  i.  234 
Sarcomata,  anatomy  of  the,  i.  232 

—  clinical  characters  of,  i.  233 

—  distribution  of,  i.  232 

—  treatment  of,  i.  236 

—  varieties  of,  i.  233 

Sayre's  treatment   of  fractured    clavicle, 

ii.  148 
Scab,  union  under  a,  ii.  32 
Scalds,  ii.  45.      See  Burns 
Scalp,  cellulitis  of  the,  i.   130 

—  contusions  of  the,  ii.  230 

—  wounds  of  the,  ii.  230 
Scapula,  dislocations  of  the,  ii.  163 

—  fracture  of  the,  ii.  149 
Scar  tissue,  changes  in,  ii.  29 

—  characters  of,  ii.  29 

—  diseases  of,  ii.  32 

—  epithelioma  of,  ii.  33 

—  formation  of,  ii.  26 

—  keloid  of,  ii.  33 

—  ulceration  of,  ii.  33 
Schizomycetes,  the,  i.  88 

Sciatic  artery,  aneurism  of  the,  iii.  56 

—  hernia,  iii.  468 

—  nerve,  operation  on  the,  iii.  206 
Sciatica,  iii.  203 

Scoliosis,  i.  272 
Scrofula,  i.  143 
Scrotum,  cellulitis  of  the,  iii.  604 

—  cleft,  i.  314 

—  dermoids  of  the,  iii.  635 

—  diseases  of  the,  iii.  604 

—  elephantiasis  of  the,  iii.  99 

—  epithelioma  of  the,  iii.  606 

—  htcmatocele  of  the,  iii.  605 

—  injuries  of  the,  ii.  351 

—  innocent  tumours  of  the,  iii.  607 
Scurvy  rickets,  iii.  m 


Scurvy,  ulceration  from,  i.  67 
Sebaceous  adenoma,  i.  263 

—  cysts,  i.  262 
.Secondary  haemorrhage,  ii.  84 
Semilunar    cartilages,     displacement    of 

the,  ii.  202 
Septic  diseases,  i.  102,  105 

—  infection,  acute,  i.  214 
chronic,  i.  216 

—  inflammation,  i.  14 

—  into.xication,  acute,  i.  106 

chronic,  i.  108 

Septicaemia,  i.  215 1 

Sequestra,  characters  of,  iii.  135 

—  separation  of,  iii.  135 
Serpiginous  spread,  i.  177,  184 

—  ulceration,  i.  184 

Serum,  anti-streptococcus,  i.  215 

—  treatment    of   malignant   tumours,   i. 

253 

of  syphilis,  i.  198 

Shock,  ii.  19 

—  urethral,  iii.  509 
Short-circuiting  the  intestine,  iii.  429 
Shoulder,  excision  of  the,  iii.  196 
Sinus,  i.  51 

Sinuses,  disinfection  of,  ii.  5 
Skin,  disinfection  of  the,  ii.  5 

—  grafting,  i.  63 

after  operations,  ii.  9 

as  a  cause  of  syphilis,  i.  170 

—  syphihs  of  the,  i.  176.     5t'^  Syphilides 
Skull,  fractures  of  the,  ii.  238 

—  haemorrhage  within  the,  ii.  243 
Sloughing  phagedeena,  i.  118 

—  ulcer,  i.  67 

Smith's,  Stephen,  amputation,  ii.  226 

Smoker's  tongue,  iii.  343 

Spermatic  cord,  diseases  of  the,  iii.  638 

hasmatocele  of  the,  iii.  642 

hydrocele  of  the,  iii.  641 

injuries  of  the,  ii.  351 

tumours  of  the,  iii.  642 

Spina  bifida,  i.  265 

false,  i.  267 

occulta,  i.  268 

Spinal  abscess,  treatment  of,  iii.  250 

—  accessory  nerve,  laceration  of  the,  ii. 

258 
operation  on  the,  iii.  206 

—  caries,  iii.  241 

cervical,  iii.  252 

dorsal,  iii.  252 

diagnosis  of,  iii.  246 

laminectomy  for,  iii.  251 

lumbar,  iii.  254 


33^ 


MANUAL   OF  SURGERY 


Spinal    caries,    morbid   anatomy  of,    iii, 
241 

prognosis  of,  iii.  247 

signs  of,  iii.  245 

treatment  of,  iii.  248 

—  column,  diseases  of  the,  iii.  241 

sprains  of  the,  ii.  269 

trephining  the,  iii.  255 

—  —  tumours  of  the,  iii.  254 
wounds  of  the,  ii.  270 

—  concussion,  ii.  266 

—  cord,  anatomy  of  the,  ii.  264 

compression  of  the,  ii.  281 

conducting  paths  of  the,  ii.  264 

diseases  of  the,  iii.  236 

division  of  the,  ii.  278 

injuries  of  the,  ii.  277 

partial  damage  of  the,  ii.  279 

tumours  of  the,  iii.  237 

—  - —  wounds  of  the,  ii.  277 

—  curvature,  i.  269 

—  meningocele,  i.  266 

Spine,    fracture -dislocation    of    the,    ii. 
272 

laminectomy  for,  ii.  275 

■ —  railway,  ii.  266 

Spirilla,  the,  i.  90 

Splay-foot,  i.  295 

Spleen,  abscess  of  the,  iii.  376 

—  cyst  of  the,  iii.  376 

—  enlarged,  iii.  376 

—  floating,  iii.  376 

—  injuries  of  the,  ii.  338 

—  removal  of  the,  iii.  377 

—  surgery  of  the,  iii.  376 
Splenectomy,  iii.  377 
Sponges,  aseptic,  ii.  3 

Spongy  hypertrophy  of  bone,  iii.  116 
Sprains,  ii.   117 

—  of  the  ankle,  ii.  175 

—  of  the  knee,  ii.  176 

—  of  the  spine,  ii.  269 

—  of  the  wrist,  ii.  143 
Staphylococcus  pyogenes  albus,  i.  40 
aureus,  i.  40 

cereus  albus,  i.  41 

cereus  flavus,  i,  41 

citreus,  i.  41 

foetidus,  i.  41 

Staphylorrhaphy,  i.  283 
Stay-knot,  the,  iii.  61 
Sterno-mastoid,  division  of  the,  i.  277 

—  tumour,  i.  277 
Sternum,  caries  of  the,  iii.  305 

—  fracture  of  the,  ii.  322 
Sthenic  fever,  i.  31 


Stomach,  abscess  round  the,  iii.  381 
■ —  foreign  bodies  in  the,  ii.  340 

—  injuries  of  the,  ii.  335 

—  operations  on  the,  iii.  382 

—  perforation  of  the,  iii.  380 

—  surgery  of  the,  iii.  378 

—  ulcer  of  the,  iii.  380 
Stomatitis,  iii.  330 

Strangulated  hernia,  iii.  450.     See  Hernia 

Strangury,  iii.  505 

Streptococcus  erysipelatis,  i.  41,  122 

—  Fehleisen's,  i.  122 

—  pyogenes,  i.  41 

Stricture  of  the  anus,  congenital,  i.  314 

—  of  the  intestine,  iii.  415 

—  of  the  oesophagus,  iii.  363 
hysterical,  iii.  365 

—  of  the  rectum,  iii.  485 
malignant,  iii.  488 

—  of  the  urethra,  iii.  581 

annular,  iii.  583 

bridle,  iii.  583 

causes  of,  iii.  581 

congestive,  iii.  593 

corkscrew,  iii.  583 

impermeable,  iii.  583 

indurated,  iii.  582 

in  women,  iii.  593 

morbid  anatomy  of,  iii.  582 

packthread,  iii.  583 

resilient,  iii.  582 

signs  of,  iii.  583 

spasmodic,  iii.  593 

treatment  of,  iii.  586 

Struma,  i.  143 

Strumous  physiognomy,  i.  144 

Stumps,  anatomy  of,  ii.  212 

—  conical,  ii.  213 

—  epithelioma  of,  ii.  214 

—  necrosis  of,  ii.  214 

—  painful,  ii.  213 

—  pathology  of,  ii.  212 

—  ulceration  of,  ii,  .214 
Styptics,  ii.  78 
Subastragaloid  amputation,  ii.  222 

—  dislocation,  ii.  205 

Subclavian  artery,  aneurism  of  the,  iii.  53 

ligature  of  the,  iii.  72 

Subdural  blood  cyst,  iii.  223 
Sublingual  dermoid,  iii.  333 
Subluxation  of  the  jaw,  ii.  289 
Submaxillary  gland,  calculus   in  duct  of 
the,  iii.  358 

• inflanunation  of  the,  iii.  357 

Sunburn,  ii.  52 

Suppuration,  i.  24,  38.      See  Abscess 


INDEX 


339 


Suppuration,  causes  of,  i.  38 

—  diffuse,  i.  46.      See  Cellulitis 

—  organisms  in,  i.  39 
Supra-condyloid  amputation,  ii.  227 
Supra-orbital  nerve,  stretching  the,  iii.  205 
Supra-pubic  cystotomy,  iii.  557 

in  women,  iii.  559 

Surgical  kidney,  iii.  518 
Sutures,  aseptic,  ii.  4 
Sylvius,  the  fissure  of,  ii.  236 
Symblepharon,  ii.  300 
Syme's  amputation,  ii.  224 

—  removal  of  the  tongue,  iii.  355 

—  repair  of  the  lip,  iii.  332 
Sympathetic  ophthalmia,  ii.  314 

—  removal  of  the  cervical,  iii.  311 
Syndactylism,  i.  307 
Syndesmotomy,  i.  299 
Synechiae,  ii.  309 

Synovitis,  acute  simple,  iii.   147 
suppurative,  iii.  151 

—  chronic,  iii.  149 

—  subacute,  iii.  149 

—  syphilitic,  i.  187  ;   iii,  171 

—  tubercular,  iii.  155 
Syphilides,  acneiform,  i.  181 

—  bullous,  i.  183 

—  congenital,  i.  201 

—  diagnosis  of,  i.  177 

—  ecthymatous,  i.  181 

—  gummatous,  i.  183 

—  impetiginous,  i.  181 

—  lenticular,  i.  179 

—  macular,  i.  178 

—  nodular,  i.  183 

—  papular,  i.  178 

—  papulo-squamous,  i.  178 

—  pigmentar}',  i.   183 

—  pustular,  i.  181 

—  pustulo-crustaceous,  i.  182 

—  roseolar,  i.  178 

—  squamous,  i.  179 

—  varieties  of  the,  i.  178 

—  vesicular,  i.  181 
Syphilis,  i.  168 

—  abortion  in,  i.  201 

—  acquired,  i.  169 

—  congenital,  i.  200 

—  definition  of,  i.  168 

—  etiology  of,  i.  168 

—  galloping,  i.  169 

—  heredo-contagion  in,  i.  168 

—  incubation  of,  i.  171 

—  initial  lesion  of,  i.  171 

—  latent,  i.  174 

—  malignant,  i.  169 


Syphilis,  micro-organisms  in,  i.   169 

—  primary,  i.   171 

—  prognosis  of,  i.  190 

—  re-infection  of,  i.  175 

—  secondary,  i.   172 

—  symptomatology  of,  i.   170 

—  tertiary,  i.  174 

—  transmission  of,  i.  200 

—  treatment  of,  i.  192 
.Syphilitic  affections  of  the  arteries,  1. 


174 


s  ;   lii.  20 

138 
222 


170 


of  the  blood-vessels,  i.  18 

of  the  bones,  i.  188  ;  iii. 

of  the  bursae,  i.  187  ;  iii, 

— -  —  of  the  eyes,  i.   189 

—  —  of  the  hair,  i.   185 

of  the  joints,  i.  187  ;  iii. 

of  the  lymphatics,  i.  186 

of  the  mucous  membranes,  i.  185 

of  the  muscles,  i.  187  ;  iii.  210 

of  the  nails,  i.  186 

of  the  nervous  system,  i,  174,  189 

of  the  nose,  iii,  259 

of  the  rectum,  iii.  485 

of  the  skin,  i.  176.     ^^^  Syphilides 

of  the  tongue,  iii.  344 

of  the  viscera,  i.  190 

—  condylomata,  i.  179 

—  fever,  i.  173 

—  lesions,  treatment  of,  i.  199 

—  pemphigus,  i.  202 

—  psoriasis,  i.  179 

—  rheumatism,  i.  174 
SvTingomj'elia,  iii.  240 
S}Tin  go -myelocele,  i.  266 

Tabetic  arthropathy,  iii.  179 
Taenia  echinococcus,  iii.  369 
Talipes,  i.  285 

—  arcuatus,  i.  294 

—  calcaneo-valgus,  i.  295 

—  calcaneus,  i.  287 

—  causes  of,  i.  285 

—  ca\-us,  i.  294 

—  equino-varus,  i.  290 

—  equinus,  i.  288 

—  general  anatomy  of,  i.  286 

—  general  treatment  of,  i.  286 

—  plantaris,  i.  294 

—  valgus,  i.  289 

—  varieties  of,  i.  285 

—  varus,  i.  289 

Tarsal  bones,  dislocation  of  the,  ii.  205 

fracture  of  the,  ii.  191 

Tarsectomy,  i.  292 

Tarsotomy,  i.  292 

Teeth,  in  congenital  syphilis,  i.  206 


340 


MANUAL   OF   SURGERY 


Temporal  artery,  ligature  of  the,  iii.  71 

—  bone,  disease  of  the,  iii.  283 
Temporo-maxillary  joint  disease,  iii.  327 
Tendo-Achillis,  rupture  of  the,  ii,   175 
Tendon-sheaths,  diseases  of  the,  iii.  213 
■ —  inflammation  of  the,  iii.  213 

—  suppuration  in  t)ie,  iii.  214  . 

—  tubercle  of  the,  iii.  217 
Tendons',  dislocation  of,  ii.  141 

—  injuries  of,  ii.   138 

—  repair  of,  ii.  140 

—  rupture  of,  ii.  139 

—  wounds  of,  ii.  139 
Teno-synovitis,  iii.  213 

—  suppurative,  iii.  214 

—  tubercular,  iii.  271 
Tenotomy,  i.  297 

—  of  the  extensors  of  the  toes,  1.  298 

—  of  the  flexor  longus  digitorum,  i.  298 

—  of  the  hamstrings,  i.  299 

—  of  the  peronei,  i.  299 

—  of  the  sterno-mastoid,  i.  277 

—  of  the  tendo-Achillis,  i.  298 

—  of  the  tibialis  anticus,  i.  298 

—  of  the  tibialis  posticus,  i.  298 
Tension  in  inflammation,  i.  14 

—  relief  of,  i.  33 
Teratomata,  i.  255 

Testicle,  abscess  of  the,  iii.  616 

—  anatomy  of  the,  iii.  608 

—  atrophy  of  the,  iii.  612 
—in  mumps,  iii.  357 

—  cystic  disease  of  the,  iii.  633 

—  dermoids  of  the,  iii.  635 

—  descent  of  the,  iii.  609 

—  diseases  of  the,  iii.  608 

—  hasmatocele  of  the,  iii.  632 

—  hernia  of  the,  iii.  622 

—  hydrocele  of  the,  iii.  628 

—  inflammation  of  the,  iii.  613 

—  injuries  of  the,  ii.  351 

—  misplaced,  iii.  609 

—  neuralgia  of  the,  iii.  612 

—  removal  of  the,  iii.  637 

—  retroversion  of  the,  iii.  611 

—  syphilis  of  the,  iii.  617 

—  transplantation  of  the,  iii.  611 

—  tubercle  of  the,  iii.  619 

—  tumours  of  the,  innocent,  iii.  632 
malignant,  iii.  636 

— -  undescended,  iii.  609 
Tetanus,  i.   136 

—  anti-toxin  in,  i.   138 

—  bacillus  of,  i.   136 

—  causes  of,  i.  136 

—  diagnosis  of,  i.  137 


Tetanus,  piognosis  of,  i.   138 

—  symptoms  of,  i.   136 

—  toxines  in,  i,   136 

—  treatment  of,  i.   138 
Thiersch's  skin-grafting,  i.  63 

Thigh,  amputation  through  the,  ii.  226 
Thoracic  viscera,  injuries  of  the,  ii.  323 

operations  on  the,  iii.  301 

Thoracoplasty,  iii.  303 
Thorax,  injuries  of  the,  ii.  319 
Throat,  cut,  ii.  289 

—  injuries  of  the,  ii.  289 
Thrombosis,  iii.  7 

—  of  cranial  sinuses,  iii.  228 
Thrombus,  organisation  of  a,  ii.  71 
Thrush,  iii.  331 

Thumb,  amputation  of  the,  ii.  215 

—  dislocation  of  the,  ii.  173 
Thyroid  cancer,  i.  255 

—  cartilage,  fracture  of  the,  ii.  292 

—  extract  in  fractures,  ii.  106 

—  gland,  anatom}-  of  the,  iii.  307 
atrophy  of  the,  iii.  307 

—  —  cancer  of  the,  iii.  311 

diseases  of  the,  iii.  307 

enlargement  of  the,  iii.  309 

inflammation  of  the,  iii.  308 

removal  of  the,  iii.  312 

removal  of  the  isthmus  of  the,  iii. 

313 
Thyroiditis,  iii.  308 
Th}TOtomy,  iii.  299 
Tibia,  dislocation  of  the,  ii.  200 
— -  —  compound,  ii.  202 

—  fractures  of  the,  ii.   187 

—  separation  of  epiphyses  of  the,  ii.  189, 
190 

Tibial  arteries,  aneurism  of  the,  iii.  57 

—  artery,  ligature  of  the  anterior,  iii.  90 
ligature  of  the  posterior,  iii.  88 

—  nerves,  operation  on  the,  iii.  207 
Tic  douloureux,  iii.  202 

Toes,  supernumerary,  i.  307 

—  webbed,  i.  307 

Tongue    abscess  of  the,  iii.  341 

—  anatomy  of  the,  iii.  339 

—  cancer  of  the,  iii.  350 

—  congenital  defects  of  the,  iii.  339 

—  cysts  of  the,  iii.  348 

—  diseases  of  the,  iii.  339 

—  geographical,  iii.  342 

—  inflammation  of  the,  iii.  340 

—  lymphangioma  of  the,  iiL  347 

—  removal  of  the,  iii.  352 

—  sarcoma  of  the,  iii.  349 

—  smoker's,  iii.  343 


INDEX 


341 


Tongue,  syphilis  of  the,  iii.  344 

—  tubercle  of  the,  iii.  346 

—  tumours  of  the,  iii.  348 

—  ulceration  of  the,  iii.  341 
Tonbillitis,  iii.  335 

—  follicular,  iii.  336 

Tonsils,  enlargement  of  the,  iii.  336 

—  inriammation  of  the,  iii.  335 

—  removal  of  the,  iii.  337 

—  tumours  of  the,  iii.  337 
Tooth,  misplaced  wisdom,  iii.  328 
Tophi,  iii.  173 

Torsion,  ii.  81 

Torticollis,  i.  276 

Toxines,  1.  92 

Trachea,  foreign  bodies  in  the,  iii.  294 

—  fracture  of  the,  ii.  293 
Tracheotomy,  iii.  296 

—  before  removal  of  the  tongue,  iii.  353 
Transfusion,  ii.  87 

Traumatic  aneurism,  ii.  58 

—  cataract,  ii.  309 

—  delirium,  ii.  24 

—  fever,  ii.  23 

—  hysteria,  ii.  266 

—  insanity,  ii.  259 
Trephining,  ii.  260  *" 

—  for  cerebral  abscess,  iii.  227 
tumour,  iii.  236 

—  for  fractured  skull,  ii.  240 

—  for  Jacksonian  epilepsy,  iii.  232 

—  for  meningeal  haemorrhage,  ii.  246 

—  for  thrombosed  lateral  sinus,  iii.  230 
Trichina  spiralis,  iii.  212 
Trichiniasis,  iii.  213 

Trismus,  i.  136.      See  Tetanus 

Trophic  lesions  after  nerve  injury,  ii.  132 

after  spinal  injury,  ii.  278 

gangrene  from,  i.  72 

Tubal  pregnancy,  iii.  656 
Tubercle,  i.  143 

—  anti-toxin  for,  i.  151 

—  bacillus  of,  i.  145 

—  caseation  of,  i.  148 

—  causes  of,  i.  144 

—  conglomerate,  i.  146 

—  crude,  i.  146 

—  development  of,  i.  146 

—  diagnosis  of,  i.  149 

—  fate  of,  i.   148 

—  heredity  in,  i.  144 

—  mode  of  infection  of,  i.  145 

—  morbid  anatomy  of,  i.  146 

—  painful  subcutaneous,  i.  240 

—  predisposition  to,  i.  143 

—  prognosis  in,  i.   150 


Tubercle,  senile,  i.  145 

—  special  seats  of,  i.  152 

—  spread  of,  i.  146 

—  treatment  of,  i.  151 
Tubercular  abscess,  i.  47,  152 

—  arthritis,  iii.  155 

—  bursitis,  iii.  222 

—  dactylitis,  iii.  129 

—  hydrarthrosis,  iii.  162 

—  laryngitis,  iii.  289 

—  lupus,  i.  153 

—  lymphadenitis,  iii.  95 

—  osteomyelitis,  iii.  129 

—  peritonitis,  iii.  385 

—  teno-synovitis,  iii.  217 

—  tissue,  fate  of,  i.  148 

—  ulcers,  i.  152 
Tuberculin,  i.  15T 
Tuberculosis,  i.   143.      See  Tubercle 
Tubo-ovarian  cysts,  iii.  662 
Tumours,  i.  222 

—  changes  in,  i.  226 

—  classification  of,  i.  230 

—  clinical  characters  of,  i.  228 

—  congenital,  i.  258 
sacral,  i.  316 

—  definition  of,  i.  222 

—  degeneration  of,  i.  226 

—  dermoid,  i.  258 

—  effects  of,  i.  228 

—  embryonic  inclusion  in,  i.  223 

—  etiology  of,  i.  222 

—  growth  of,  i.  225 

—  heredity  of,  i.  223 

—  injury  causing,  i.  224 

—  innocent,  i.  228 

—  malignant,  i.  229 

—  number  of,  i.  228 

—  origin  in  vestiges  of,  i.  224 

—  parasitic  origin  of,  i.  225 

—  secondary  growths  of,  i.  230 

—  ulceration  of,  i.  68 

Tunica  vaginalis,  anatomy  of  the,  iii.  609 

haematocele  of  the,  iii.  630 

hydrocele  of  the,  iii.  622 

inflammation  of  the,  iii.  630 

Tympanic   cavity,    inflammation   of  the, 
iii.  276 

—  membrane,  injuries  of  the,  iii.  275 
Typhomania,  i.  217 

Ulcer,  annular,  i.  65 

—  callous,  i.  65 

—  diabetic,  i.  67 

—  duodenal,  ii.  48 
—  gastric,  iii.  380 


342 


MANUAL   OF   SURGERY 


Ulcer,  gouty,  i.  68 

—  haemorrhage,  i.  66 

—  indolent,  i.  65 

—  inflamed,  i.  67 

—  irritable,  i.  66 

—  malignant,  i.  68 

—  mercurial,  i.   194 

—  perforating,  iii.  201 

—  rodent,  i.  257 

—  scorbutic,  i.  67 

—  simple,  i.  56 

—  sloughing,  i.  67 

—  specific,  i.  67 

—  syphilitic,  i.  184 

—  tubercular,  i.  152 

—  varicose,  i.  66 
Ulcer,  weak,  i.  65 

Ulcerated  surfaces,  disinfection  of,  ii.  5 
Ulceration,  i.  56.      See  Ulcer 

—  causes  of,  i.  56 

—  infective,  i.  68 

—  of  cartilage,  iii.  152 

—  of  scars,  ii.  33 

—  of  stumps,  ii.  214 

—  serpiginous,  i.  184 

—  skin-grafting  in,  i.  63  " 

—  varieties  of,  i.  64 

Ulna,  fractures  of  the,  ii.  160 
Ulnar  artery,  aneurism  of  the,  iii.  55 

ligature  of  the,  iii.  79 

Umbilical  hernia,  iii.  465 
Unconsciousness,  diagnosis  of  the  cause 

of,  ii.  248 
Union  of  wounds,  ii.  26 

—  by  first  intention,  ii.  30 

—  by  second  intention,  ii.  31 

—  of  granulating  surfaces,  ii.  32 

—  under  a  scab,  ii.  32 
Ununited  fracture,  ii.  103 

of  the  patella,  ii.  187 

thyroid  extract  for,  ii.  106 

wiring  for,  ii.  106 

Upper  limb,  injuries  of  the,  ii.  142 
Urachus,  cysts  of  the,  i.  313 

—  patent,  i.  313 
Uraemic  coma,  ii.  249 
Uranoplasty,  i.  284 

Urea,  estimation  of,  iii.  496 
Ureter,  calculus  in  the,  iii.  527 
Urethra,  anatomy  of  the,  iii.  576 

—  chancre  in  the,  iii.  578 

—  contusions  of  the,  ii.  344 

—  diseases  of  the,  iii.  576 

—  foreign  bodies  in  the,  ii.  343 

—  granular,  iii.  579 

—  imperforate,  i.  310 


Urethra,  inflammation  of  the,  iii.  577 
gonorrhoeal,  i.   156 

—  injuries  of  the,  ii.  343 

—  malformations  of  the,  i.  310 

—  physical  examination  of  the,  iii.  584 

—  rupture  of  the,  ii.  344 

—  stricture     of     the,     iii.      58  r  See 

Stricture 

—  tumours  of  the,  iii.  594 
Urethral  fever,  iii.  508 

—  rheumatism,  i.  164 

—  shock,  iii.  509 
Urethritis,  gonorrhoeal,  i.  156 

—  non-gonorrhoeal,  iii.  577 
Urethrotomy,  external,  iii.  589 

—  internal,  iii.  588 
Urinary  fever,  iii.  508 

—  organs,  diseases  of  the,  iii.  495 

—  sepsis,  iii.  510 
Urine,  abnormal,  iii.  495 

—  extravasation  of,  ii.  346 

—  incontinence  of,  iii.  500 

—  normal,  iii.  495 

—  retention  of,  acute,  iii.  503 

chronic,  iii.  501 

effects  of,  iii.  506 

Uterus,  amputation  of  the  cervix  ol  the, 
iii.  653 

—  cancer  of  the,  iii.  650 

—  diseases  of  the,  iii.  649 

—  fibroids  of  the,  iii.  649 

—  removal  of  the,  iii.  651 

—  rupture  of  the,  ii.  355 
Uvula,  diseases  of  the,  iii.  338 

Vaccination  causing  syphilis,  i.  170 
Vagina,  disease  of  the,  iii.  645 

—  disinfection  of  the,  ii.  6 

—  foreign  bodies  in  the,  ii.  354 

—  inflammation  of  the,  iii.  646 

—  laceration  of  the,  ii.  354 

\'agus  nerve,  laceration  of  the,  ii.  258 
Varicocele,  iii.  638 
Varicose  aneurism,  ii.  62 

—  ulcer,  i.  66 

—  veins,  iii.   13 

treatment  of,  iii.  16 

Varix,  iii.  13 

—  aneurismal,  ii.  61 

—  arterial,  iii.  3 

—  lymphatic,  iii.  98 
\'ascular  caruncle,  iii.   594 
Vasectomy,  iii.  572 
Veins,  air  in  the,  ii.  63 

—  canalisation  of,  ii.  64 

—  diseases  of  the,  iii.  7 


INDEX 


343 


Veins,  inflammation  of  the,  iii.  lo 

—  injuries  of  the,  ii.  63 

—  thrombosis  of  the,  iii.  7 

—  varicose,  iii.  13 
\'enereal  diseases,  i.  156 
\'cnous  thrombosis,  iii.  7 

intracranial,  iii.  228 

Ventral  hernia,  iii.  467 

Ventricles,  aspiration  of  the  cerebral,  iii. 

234 

—  drainage'of  the  cerebral,  iii.  234 
Vermiform  appendi.x.      See  Appendix 
Vertebral  artery,  ligature  of  the,  iii.  74 
Vesico-vaginal  fistula,  iii.  648 
Vesiculoe  seminales,  diseases  of  the,   iii. 

643 

inflammation  of  the,  iii.  643 

tubercle  of  the,  iii.  644 

Vessels,  injuries  of  the,  ii.  56 

gun-shot,  ii.  39 

Vestiges,  origin  of  tumours  in,  i.  224 
Vicious  union  of  fractures,  ii.  107 
Viscera,  affections  of,  by  burns,  ii.  47 

—  gun-shot  injury  of  the,  ii.  40 
Vitreous,  haemorrhage  into  the,  ii.  304 
Volvulus,  iii.  408 

Vulva,  haematoma  of  the,  ii.  353 

—  injuries  of  the,  ii.  353 

Wart,  anatomical,  i.  153 

—  gonorrhoeal,  i.  167 
Wen,  i.  262 

Wheelhouse's  operation,  iii.  589 


Whitehead's  operation  for  piles,  iii.  483 

for  removal  of  the  tongue,  iii.  353 

White-swelling,  iii.  155 

syphilitic,  i.  187  ;  iii.  171 

Whitlow,  iii.  214 
Wiring  fractures,  ii.  100 

—  the  patella,  ii.   184 
Wound-diphtheria,  i.  119 
Wounds,  contused,  ii.  18 

—  disinfection  of,  ii.  12 

—  drainage  of,  ii.  14 

—  dressings  for,  ii.  14 

—  incised,  ii.   17 

—  inflammation  of,  ii.  33 

—  lacerated,  ii.  18 

—  open,  ii.  17 

—  penetrating,  ii.  18 

—  poisoned,  ii.  17 

—  punctured,  ii.  18 

—  repair  of,  ii.  26 

—  subcutaneous,  ii.  17 

—  suturing,  ii.  13 

—  treatment  of,  ii.  12 

—  varieties  of,  ii.  17 

Wrist,  dislocation  of  the,  ii,  172 

—  excision  of  the,  iii.  198 

—  sprained,  ii.  143 

—  wounds  of  the,  ii.  143 
Wryneck,  i.  276.      See  Torticollis 

Yeasts,  i,  88 

Zygoma,  fracture  of  the,  ii.  285 


END    OF    VOL.   I 


|MacmilUn^9  ]VIa"u*^l9  of  Medicine  and  Surgery 

INTRODUCTION 

THE   OUTLINES   OF   THE  PRINCIPLES  OF 
DIFFERENTIAL   DIAGNOSIS 

WITH 

CLINICAL    MEMORANDA 

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fection. 

III.  Micro-organisms  and  disease. 

IV.  Diseases  of  thoracic  organs. 

IV.  {Continued)     Heart  and  pericardium. 

V.  Diseases  of  nose,  throat,  and  alimentary  system. 

VI.  Diseases  of  the  urinary  organs. 

VII.  Affections  of  joints. 

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